An-Najah National University Faculty of Graduate Studies FACTORS AFFECTING PATTERNS OF MANAGERIAL DECISION-MAKING IN GOVERNMENTAL HOSPITALS IN THE NORTHERN WEST BANK – PALESTINE, A QUALITATIVE STUDY By Ola Arafat Bny-Fadel Supervisor Dr. Muhammed Marie This Thesis is Submitted in Partial Fulfillment of the Requirements for the Degree of Master of Public Health Management, Faculty of Graduate Studies, An-Najah National University, Nablus, Palestine. 2025 ii FACTORS AFFECTING PATTERNS OF MANAGERIAL DECISION-MAKING IN GOVERNMENTAL HOSPITALS IN THE NORTHERN WEST BANK – PALESTINE, A QUALITATIVE STUDY By Ola Arafat Bny-Fadel This Thesis was Defended Successfully on 14/05/2025 and approved by Dr. Muhammed Marie Supervisor Signature Dr. kawther Alessa External Examiner Signature Dr. Nizar Said Internal Examiner Signature iii Dedication I dedicate this master's thesis to my family who always supported me when I was working on my master's thesis. And to my family who helped me get the courage to finish my master's degree، To everyone who supported me and helped me achieve my goal and successfully complete my dissertation. Sincerely iv Acknowledgements I would like to thank my family for bearing with me the difficulties of this stage. I praise the efforts of my supervisor, Dr. Muhammad Marhi, for his patience and cooperation. I would like to thank everyone who taught me in the Public Health Administration program and had every impact on my development. I also greatly appreciate the administrative directors who agreed to participate in this study and contribute to the current research. This was not the case. The study would have been possible without the help of a number of people, including my family, friends and others. v Declaration I, the undersigned, declare that I submitted the thesis entitled: FACTORS AFFECTING PATTERNS OF MANAGERIAL DECISION-MAKING IN GOVERNMENTAL HOSPITALS IN THE NORTHERN WEST BANK – PALESTINE, A QUALITATIVE STUDY I declare that the work provided in this thesis, unless otherwise referenced, is the researcher’s own work, and has not been submitted elsewhere for any other degree or qualification. vi List of Contents Dedication ...................................................................................................................... iii Acknowledgements ...................................................................................................... iv Declaration ...................................................................................................................... v List of Contents ............................................................................................................. vi List of Tables ................................................................................................................. ix List of Figures................................................................................................................. x List of Appendices ........................................................................................................ xi Abstract ........................................................................................................................... xii Chapter One: Introduction and Theoretical Background .................................................. 1 1.1 Introduction ................................................................................................................. 1 1.2 Problem Statement ...................................................................................................... 6 1.3 The importance of study ............................................................................................. 7 1.3.1 Theoretical significance ........................................................................................... 7 1.3.2 Applied importance .................................................................................................. 8 1.4 Aim of study ............................................................................................................... 9 1.5 Study Objectives ......................................................................................................... 9 1.6 Questions of Study ...................................................................................................... 9 1.7 Concepts and Operational Definition ......................................................................... 9 1.7.1 Operational definition ............................................................................................ 11 1.7.2 Operational definition ............................................................................................ 11 1.8 Previous Studies and Theoretical Background ......................................................... 11 1.9 Gap of literature review ............................................................................................ 17 Chapter Two: The Methodology ..................................................................................... 18 2.1 Study design .............................................................................................................. 18 2.2 Study Setting ............................................................................................................. 18 2.3 Study population ....................................................................................................... 18 2.4 Study sample ............................................................................................................. 19 2.5 Research approach .................................................................................................... 19 2.6 Data collection methods ............................................................................................ 21 vii 2.6.1 Types of Interviews ............................................................................................... 22 2.6.2 Procedures related to the interview ........................................................................ 23 2.6.3 Post-Interview Procedures ..................................................................................... 25 2.7 Working Plan ............................................................................................................ 27 2.8 Data Analysis ............................................................................................................ 27 2.9 Generalizability ......................................................................................................... 29 2.10 Validity and Reliability ........................................................................................... 30 2.11 Ethical Issues .......................................................................................................... 30 2.12 Research contributions ............................................................................................ 30 2.13 Translation .............................................................................................................. 31 2.14 Reflexivity .............................................................................................................. 31 2.15 Conclusion .............................................................................................................. 31 Chapter Three Result ...................................................................................................... 32 3.1 Socio demographic characteristic ............................................................................. 32 3.2 The first question ...................................................................................................... 33 3.3 The second question .................................................................................................. 37 3.3.1 Them Financial constraints .................................................................................... 42 3.3.2 Them Leadership Styles ......................................................................................... 43 3.3.3 Them Challenges ................................................................................................... 43 3.3.4 Interlinked Challenges ........................................................................................... 44 3.4 The Third question .................................................................................................... 45 Chapter Four: Discussion, Conclusion, Recommendation ............................................. 47 4.1 Discussion ................................................................................................................. 47 4.2 Demographic variables ............................................................................................. 47 4.3 factors that affect managerial decision-making in government hospitals in the northern West Bank ................................................................................................. 48 4.4 Conclusion ................................................................................................................ 55 4.5 Limitation of the study .............................................................................................. 56 4.6 Strengths of the study ............................................................................................... 56 4.7 Recommendation ...................................................................................................... 57 4.7.1 Recommendations for Policy maker ...................................................................... 57 viii 4.7.2 Recommendation for further study ........................................................................ 57 References ....................................................................................................................... 59 Appendices ...................................................................................................................... 64 ABCDEب ............................................................................................................................... ا ix List of Tables Table 3.1: Socio demographic characteristic (n=15) ...................................................... 33 Table 3.2: Codes for Question 1 ..................................................................................... 35 Table 3.3: Keyword for Question 2 Analysis ................................................................. 40 Table 3.4: Keyword Table for Question 2 Analysis ....................................................... 41 x List of Figures Figure 3.1: Relationship between demographic variables and decision – making factors ........................................................................................................ 46 xi List of Appendices Appendix A: Consent form ............................................................................................. 64 Appendix B: Interview questions ................................................................................... 65 Appendix C: IRB ............................................................................................................ 66 Appendix D: Validation to facilitate the task ................................................................. 67 Appendix E: Approval of the Ministry of Health ........................................................... 68 Appendix F: ANVIVO Analysis: Organized Interviews ................................................ 69 Appendix G: Interview Responses for (Q1&Q2) summary ........................................... 71 xii FACTORS AFFECTING PATTERNS OF MANAGERIAL DECISION- MAKING IN GOVERNMENTAL HOSPITALS IN THE NORTHERN WEST BANK – PALESTINE, A QUALITATIVE STUDY By Ola Arafat Bny-Fadel Supervisor Dr. Muhammed Marie Abstract Background: Decision-making in public hospitals is challenged by multiple, constantly shifting political, financial and leadership considerations. The unstable environments and lack of resources in developing regions such as Northern West Bank present challenges that add further complexity to the intricacies of the decision-making process. The purpose of this study is to explore the factors affecting managerial decision-making in governmental hospitals in Northern West Bank. It looks into the impact of political pressures, monetary constraints, and leadership styles upon decision-making while observing the influence of demographic variables such as age, gender, level of education, and administrative experience. A qualitative approach was used, and data was collected through semi-structured interviews. 15 administrative and technical directors in government hospitals in the northern West Bank were interviewed. Thematic analysis was conducted using NVivo software, coding responses into themes and subthemes, including political factors, financial constraints, and leadership styles. Demographic characteristics were also analyzed to evaluate their influence on the decision-making process. The study found political pressures-such as directives from outside entities and unstable environments-and financial constraints, such as limited resources and budget constraints, as factors with the strongest impact on decision-making. Transformational and participatory leadership styles have strong connotations of effectiveness; however, they do meet with difficulty in implementation owing to systemic reasons. In addition, among demographic characteristics, administrative experience and age are the two that are most influential—experienced managers demonstrate a greater ability to adapt and solve problems. xiii In sheer terms, external political and financial challenges play an overriding role in managerial decision-making in the public hospitals of the Northern West Bank. Although leadership styles may countermeasure these factors, their effectiveness is largely curtailed owing to systemic impediments. Age and experience further enhance decision-making effectiveness. This makes it imperative to call for ensuring adequate authority to hospital managers, independent resource mobilization and investment in leadership development programs directed at improving decision-making in public health systems. Keywords: hospitals, decision-making, factor affecting, Palestine, managerial director. 1 Chapter One Introduction and Theoretical Background This chapter deals in detail with the problem that this study focused on. It is divided into four parts: The first part, which consists of an introduction to the study, a statement of the study problem, a discussion of the importance of this study, the purpose and objectives, and research questions. The second part, discusses operational concepts and definitions. The third part, presented the previous studies related to the research problem. 1.1 Introduction Managerial decision-making is at the heart of the success of any organization, as it becomes the bedrock of achieving strategic goals and performing effective operational functions. Now, this significance of decision-making is even increased in hospitals in the northern West Bank where the need for better quality healthcare service delivery to communities is vital. It is important to develop understanding of the constructs which drive managerial decision-making as they relate to the circumstantial factors behind better onboarding of administrative processes through informed and data-backed decision-making (AlFlayyeh & Al-Harbi, 2023). The study was do an analytical survey of some of the factors that affect the making of decisions, either organizational, economic, technological, or social-or combination thereof-as they suggest implications for internal and external environments. Such considerations include any general economic and political challenges that shape the framework through which such decision-making transpires. Shlash,(2020). The exploration of human factors is also relevant in determining the extent to which such elements influence outcomes: It includes experience and training levels of managerial leaders,(Al-Tawil, 2017). This study therefore seeks to identify those factors and then investigate how they interact to develop strategies for improving decision-making processes in the hospitals of the region (AlFlayyeh & Al-Harbi, 2023). The institutions, organizations, and agencies tasked with ensuring that residents of a community have access to healthcare are collectively referred to as the health care s, sometimes known as the medical care system (Szymaniec-Mlicka, 2017). 2 Due to the complexity of the healthcare industry, the fierce competition in the healthcare services market, and the requirement for high-quality services, health organizations have implemented innovative management strategies (Koning, 2022). The political environments of health institutions, the accessibility of financial resources, administrative patterns, and cultural frameworks are all important factors that have a big impact on administrative decision-making in the health sector (Kavosi et al., 2018). One of the processes in a complicated decision-making process is the choice itself. Other steps include identifying the decision problem, deciding on the selection criteria, developing and analyzing decision-making variations (Szymaniec-Mlicka, 2017). In healthcare institutions, an administrative decision is one that has been taken by the administrative body or authority inside the facility. a decision or judgement that has an impact on the management, operation, policies, procedures, or practices of an organization (AlFlayyeh & Al-Harbi, 2023). Budgeting, staffing, resource allocation, facilities management, regulatory compliance, and strategic planning are just a few of the many areas where management decisions can be made (AlFlayyeh & Al-Harbi. 2023), People or groups who have managerial positions inside the organization, such as executive directors, directors, or boards of directors, typically make these decisions, they are in charge of making sure the healthcare organization is managed effectively and efficiently (Beaglehole & Poz, 2023). Patterns of decision-making in health care institutions, especially in government hospitals, are affected by a number of factors, the most important of which is the organizational structure of health organizations through which they achieve their goals by determining the manner and extent to which roles, authorities, and duties are assigned and coordinated to achieve organizational goals (Sipayung, Ginting,, & Sibarani, 2021). so that it controls who has the power to make decisions within the healthcare organization. In hierarchical systems, such as the conventional bureaucratic model, which often features a centralized decision-making process, senior executives typically make the majority of decisions (Abane, Abubakari, & Asamoa, 2020). Decentralized structures, such as matrix or team-based models, on the other hand, give decision-making authority to lower-level employees or niche teams (Winasti, Berden , & Merode , 2023). 3 Hospital managerial decision-making is significantly influenced by the political climate. Politics has a significant impact on how hospitals run and the decisions that administrators make, including healthcare policy, governmental laws, and funding systems (Christensen, 2020). Modifications to healthcare legislation may result in modifications to payment schemes or the introduction of new quality criteria, both of which have an immediate effect on how hospital managerial make decisions (Yearby, Clark, & Figueroa, 2022). Political issues also influence administrative decision-making in hospitals. Hospital collaboration with other health care organizations, such as physician groups, long-term care facilities, or community health centers, is often encouraged or mandated by health care laws and legislation (Szymaniec-Mlicka, 2017). To successfully navigate the political landscape and satisfy the demands set by politicians, hospital administrators must assess potential alliances, bargain deals, and decide how to allocate resources (Yearby, Clark, & Figueroa, 2022). In government hospitals, managerial decision-making is greatly influenced by leadership style. The total effectiveness and efficiency of healthcare management can be significantly impacted by the decision-making process used by executives (Teame, Debie, & Tullu , 2022). There are many different leaderships style, including autocratic leadership, in which the decision-making authority rests solely with one leader who takes choices without seeking input from or involving others. Government hospitals may experience detrimental effects from this approach to administrative decision-making. According to research by Shrivastava (Albejaidi, Kundi , & Mughal , 2020), autocratic leaders frequently disregard the helpful perspectives and experiences of others in favor of their own preferences and beliefs when making decisions (Chukwusa, 2018). Another form of leadership that emphasizes shared decision-making is democratic leadership, in which team members are actively sought out before decisions are made. This approach may have a favorable impact on how government hospitals make administrative decisions (Albejaidi et al., 2020). Democratic leadership improves teamwork, communication, and employee involvement, which results in higher-quality decisions and more fulfilling work. by including staff members in decision-making processes, particularly healthcare professionals (Editorial Team, 2023). Management choices made in public hospitals benefit from a transformational leadership approach, through which 4 patient care outcomes and organizational performance are enhanced, which in turn encourages a proactive and creative approach to decision-making, by promoting a culture of trust, empowerment and continuous learning (Albejaidi et al., 2020). Whereas in a laissez-faire (authoritarian) approach, the leader takes a passive role and provides little direction or input during the decision-making process. Since it has a detrimental impact on decision quality, employee satisfaction, and overall organizational performance, such leadership has negative effects on managerial decision-making in hospitals,Iqbal, et al., (2021). Decision-making procedures may lack structure, coordination, and accountability in the absence of clear direction or active leadership involvement, which could produce less-than-ideal results and impair the effectiveness of healthcare administration (Rabhi, Affaf, Thamri, & Djoual, 2023). The availability of financial, human and technological resources is a factor that affects decision-making in hospitals, as obtaining sufficient financial resources is necessary to make decisions with a positive impact (Grossi, et al., 2021). Lack of resources can limit the scope of services provided, lower the level of health care provided, and restrict access to basic tools.(Abeje & Tegegne, 2024). On the other hand, having enough money allows hospitals to make investments in cutting-edge technology, recruit and keep talented medical staff, and enhance patient care in general (Wang, Xiang, & Dong, 2023). Hospitals are able to provide the right care at the right time, make informed decisions about patient care, and manage health care operations efficiently when they have adequate staffing levels and qualified personnel. A lack of human resources can lead to increased workloads, a risk to patient safety, and difficulty meeting population growth expectations (Alamdtv et al, 2016). Within government hospitals, the availability of cutting-edge technology resources is vital to decision-making. Hospitals are now able to diagnose, treat, and monitor patients more effectively because to modern healthcare technologies including electronic health records, diagnostic tools, telemedicine, and data analytics (Lina Weinert et al.,2022). Access to technology supports effective healthcare delivery, improves communication and collaboration among healthcare professionals, and facilitates decision-making based on evidence (silva et al.,2015) On the other hand, the legal and regulatory factor greatly affects how government hospitals make administrative decisions. In addition to ensuring accountability, openness, and adherence to standards, it provides a set of rules, policies, 5 and procedures that regulate the work of these organizations (Chan, 2019). Government hospital operations, plans and policies are significantly influenced by management decisions made under the influence of stakeholders, including patients, healthcare professionals, administrative staff, government agencies, policy makers, community organizations and the general public who are stakeholders in the context of government hospitals (Malfait et al., 2017). A malty challenge that decision-makers in the Palestinian environment must overcome have a big influence on administrative decision-making. These challenges come in a variety of forms and encompass social, political, economic, and technical elements. The most important elements affecting administrative decision-making in the Palestinian setting are as follows: The first challenge is Political Challenges: the restrictions imposed by the occupation on Palestinian lands, military checkpoints, and control over natural resources are among the most prominent factors limiting the ability of Palestinian decision-makers to make free and effective managerial decisions (Malfait et al., 2017). The second challenge is Economic Difficulties: The Palestinian economy is severely underfunded and understaffed, which makes it challenging to make administrative choices in sectors like infrastructure, health care, and education (Malfait et al., 2017), the third challenges is Social Challenges: Due to the great sociocultural diversity of Palestinian society, particularly in the West Bank and Gaza, it can be challenging to achieve choices that involve all social groups. Fourth challenges is Legal challenges: The stability of processes and the efficacy of outcomes are impacted by the Palestinian legal system's poor application of legislation pertaining to administrative decisions (Fassberg, 1994). The managerial decision-making process is further complicated by the overlap between the Israeli and Palestinian legal systems in the occupied areas. varied Palestinian regions have varied social demands, which makes administrative decisions that must take into account these various demands even more difficult. According to Badour et al. (2015) the pattern of managerial decision-making in government hospitals can be significantly influenced by the external environment. These effects include: 6 First, regulatory and legal factors, which ensure that public hospitals function within the confines of the rules and laws that direct their decision-making. The kinds of decisions managers can make and the procedures they must follow are influenced by external regulations, policies, and legal obligations. Second, political and economic factors: Political and economic influences can have an impact on governmental hospitals' decision-making. Resource allocation, staffing choices, and strategy planning can all be impacted by changes in government policies, funding allotments, and budget restrictions. Third, socio-demographic factors: These include things like population growth, ageing demographics, income levels, and cultural diversity, which can affect service demand, resource allocation, and the creation of specialized healthcare programmers. Fourth, technological developments: Advances in information technology and health care may have an impact on managerial choices. Technological developments have the potential to change the way health care is delivered, increase efficiency, and provide new treatment alternatives. Hospital managers must decide whether to accept and use new technology given the external technology landscape. Fifth, the external competitive environment can influence how government hospitals make decisions, i.e., the competitive landscape. Resource allocation, marketing tactics, and service delivery patterns may be affected by the presence of private healthcare providers, market dynamics, and consumer preferences for alternative healthcare options. Governmental hospitals may need to make choices that increase their competitiveness and meet the changing demands of patients (Pierce et al., 2021). 1.2 Problem Statement Within the field of healthcare management, the decision-making process that takes place in governmental hospitals is crucial in determining the efficacy, efficiency, and general quality of healthcare services. The variables affecting the managerial decision- making practices in these organizations, however, are still a complicated and little- studied field of study. Optimizing resource allocation, improving patient care, and building organizational resilience all depend on an understanding of the subtleties of decision-making in governmental hospitals.In order to improve the health of the population and provide them with a suitable healthy environment, the Palestinian 7 Ministry of Health has worked since 1994 to improve health care in all its institutions, so that hospitals are the primary point of contact for the general public. The aim of this qualitative study is to close the current knowledge gap by thoroughly examining the variables influencing managerial decision-making practices in government hospitals. Through an exploration of the experiences, perspectives, and obstacles encountered by healthcare managers, this research aims to clarify the complex interactions between factors influencing the processes of making decisions. The results will benefit academic research as well as policymakers, hospital managers, and healthcare professionals who want to improve the frameworks used for making decisions in government-run healthcare facilities. In conclusion, by examining the variables influencing managerial decision-making in governmental hospitals, this study fills a significant vacuum in the literature and lays the groundwork for evidence-based interventions that can enhance decision-making procedures and, as a result, raise the general efficacy of healthcare services provided by the public sector. 1.3 The importance of study Investigating the factors affecting managerial decision-making in public hospitals is important from a theoretical point of view and important from an applied point of view. 1.3.1 Theoretical significance • Understanding of organizational behavior in government hospitals can be improved by researching the trends of managerial decision-making. Provides insight into the decision-making process, the different role of stakeholders, and the dynamics affecting them. This improves our understanding of organizational structures, communication patterns, power relations, and decision-making theories in setting up health care institutions through this research. • Government and Public Administration: Government hospitals are a component of the larger public administration system. Theories and models of public administration and governance are improved by understanding the elements that affect administrative decision-making. It clarifies the difficulties involved in making decisions in the public sector, including the impact of political, legal, and regulatory considerations on healthcare management. 8 • Policy Studies: It is important to understand the variables that affect choices in public hospitals. Assists in reviewing how health care policies and programs are put into practice, identifying inconsistencies between policy goals and outcomes, and evaluating the effectiveness of policy interventions. This research can support efforts to evaluate and improve policies and build evidence-based policies 1.3.2 Applied importance • Effective management and leadership within government hospitals depend heavily on the research of decision-making elements. Managers and leaders can create strategies to support informed and sound decision-making processes by understanding the impacts on decision-making. A culture of evidence-based decision-making must be fostered, and this involves recognising leadership styles that encourage efficient decision-making, fostering collaboration and communication among healthcare professionals, and more. • Performance Enhancement: Examining the elements that influence decisions can help government hospitals perform better. Interventions aiming at improving organizational effectiveness, cutting down on bureaucracy, and streamlining procedures can be informed by identifying the obstacles to and enablers of successful decision-making. This study has the potential to enhance the delivery of healthcare services overall by increasing productivity, decreasing waiting times, and improving patient happiness. • Relevance to Policy and Practice: Knowing what influences decisions makes the gap between research and practice less. The findings can be used by practitioners and policymakers in government hospitals to guide frameworks for strategic planning, policy formation, and decision-making. This research makes ensuring that choices are in line with what patients, the public, and the larger healthcare system need. • Healthcare System Strengthening: Research on decision-making factors helps to make healthcare systems stronger. Policymakers can address systemic problems and adopt reforms that improve the efficiency, equality, and effectiveness of healthcare services by recognizing the factors that influence decision-making. This entails enhancing accountability frameworks, fortifying governance processes, and effectively allocating resources within the healthcare system. 9 1.4 Aim of study Exploring the basic factors that affect managerial decision-making in government hospitals in the northern West Bank. 1.5 Study Objectives • To Explore the basic factors that influence managerial decision-making in governmental hospitals, including political influences, financial resources and constraints, and leadership styles in governmental hospitals in the northern West Bank. • Analysis of demographic variables (gender, age, administrative experience, and level of education), and the extent of their impact on managerial decision-making. • •To Explore the factors influencing administrative decision-making based on demographic variables of hospital managers (such as age, gender, educational level, and administrative experience) in government hospitals in the northern West Bank. 1.6 Questions of Study • What are the factors that influence managerial decision-making in governmental hospital? • What is the influence of demographic variables (gender, age, administrative experience, educational level) To make administrative decisions? • Is their relationship between the demographic variables of the participants and the factors that affect administrative decision-making in hospitals in the northern West Bank? .1 7 Concepts and Operational Definition Conceptual definitions of public health management, administrative decision-making in health care, while operational definitions are factors that affect decision-making in hospitals, including: Organizational Structure, Political Environment, Leadership Style, Resource Availability, Legal and Regulatory Framework, Stakeholder Influence, External Environment. healthcare management is the practice of giving leadership, management, and direction to various departments within enterprises that offer healthcare services. Effectiveness, 10 efficiency, and equity are the three main concepts at the center of healthcare management. (About Health Management. EHMA. 2022, December 18) Our hospitals and doctors' offices work smoothly because of the support and guidance provided by health care managers and administrators, who guarantee patients receive the greatest care. These unsung heroes make a significant contribution to the creation of new medical goods and services that support regional populations, empower medical professionals, and improve treatment options (Team, 2024). Managerial decision-making in healthcare: refers to the process by which healthcare managers or managerial decisions- making and take measures to realize organizational objectives and enhance healthcare delivery. It entails deciphering intricate data, taking into account many options, assessing prospective results, and deciding on the best course of action. In healthcare, managerial decision-making plays a crucial role in a wide range of areas, including: Resource Allocation, Strategic Planning, Policy Development, Quality Improvement, Healthcare Technology, Collaborative Decision- making (Hedayatipour et al.,2024). Political considerations:Refers to the set of external influences and pressures that come from the political environment (such as government policies, laws, and regulations) that influence administrative decisions in hospitals. It also includes relationships with political parties or the effects of public health policies on hospital performance (Cumpăt, 2024). Barriers to financial resources: Obstacles that hospitals encounter in efficiently acquiring or employing financial resources include lack of financing, excessive costs, and resource mismanagement. (Beaglehole & Poz, 2023). Types of leadership Leadership types refer to the styles that leaders take in managing hospitals, and include transformational leadership (which focuses on motivation and inspiration), autocratic leadership (which relies on centralized decisions), and participative leadership (which relies on team involvement). 11 1.7.1 Operational definition Political considerations are measured by analyzing the extent to which government laws and policies influence administrative decisions in hospitals through semi -structured interview addressed to executives. Financial resources are the funds available to manage and operate hospitals, which include government funding, self-revenue, donations, and expenses. Financial resources management is an essential element in administrative decision-making to ensure the sustainability of operations and provision of health services Managerial decisions- Making: It is the process of identifying the most effective methods and choices to fulfil the organization's health objectives. This process involves planning, evaluating, and implementing depending on available data, health requirements, and external pressures (Hardiansyah, Indrawati, & Nofierni, 2024). 1.7.2 Operational definition The decision-making process is measured by monitoring the planning and implementation steps, and conducting interviews with administrators to determine the extent of their use of modern tools in managing decisions. .1 8 Previous Studies and Theoretical Background Previously published papers were used, which discussed the same title, objectives, and keywords for this study. This gives us access to a robust database for our research. The keywords used in the database search process are: Decision, decision-making, factors affecting decision-making, managers, hospitals. A set of keywords linked to the study title and study objectives were pre-selected The literature review of scientific research is the basis for clarifying the researchers' approach to topics related to the research topic. Previous studies are considered a nucleus for drawing scientific frameworks for research, as it is not possible to establish any scientific research without previous studies. The following is a presentation of the most important studies available to researchers from previous studies that have been addressed. The subject of this study, some of which are directly related to the current study and others are partly related to its components. The focus was on the main objectives of the studies and the most 12 important results that were reached so that we can compare them with the results of the current research. There were many studies that discussed research tittle such as: In China the study was conducted by Jiaxiang et al. (2024) the aim of the study was to explore the factors influencing the development of university hospitals. A qualitative study in which the researcher used value theory, where he conducted semi-structured interviews on 15 directors from university hospitals in China. The results indicated that political influence and leadership issues significantly affect decision-making. The study was conducted by Teame et al. (2022), aimed to evaluate the leadership capabilities of health care managers and analyze the factors associated with effective leadership. A triangulated design was used for the cross-sectional study that was based on organizations. Participants were randomly selected after multistage sampling. A binary logistic regression model was used to identify variables associated with effective leadership along with interviews with key stakeholders (KIIs) to analyze their perspectives. 844 health care managers participated in the study. The results indicated that 46.8% of participants use effective leadership styles. The results also showed a positive relationship between practical experience and effective leadership. It also indicated that authoritarian leaders negatively affected managers' ability to cooperate and motivate employees. Managers with emotional intelligence interacted positively with employees, allowing them to express their needs.On the other wise, the study was conducted in Iranian, by Mosadeghrad (2014), The study aimed to analyze the quality of health services and the impact of financial resources on management. A mixed approach of quantitative and qualitative study was used, as the study was carried out through a questionnaire and interviews with 100 participants among Iranian hospital managers. The results indicated that the lack of financial resources hampers management decisions. While the study was conducted by Aberese-Ako et al. (2018), it aimed to compare leadership styles in the Ghanaian hospital environment. The descriptive analytical approach was used. Questionnaires and objective analysis were used for a sample of 200 health employees. The results indicated that transformational leadership improves decision making within limited financial resources. while, the study was conducted in Iran by Asiabar et al. (2019), the study aimed to evaluate the effectiveness of leadership in managing Iranian hospitals. A qualitative approach was used, where interviews were conducted on a sample of 50 hospital directors. In Pakistan, by the 13 study was conducted by Sharma & Seetharaman (2022), this study aims to pinpoint several factors that affect decision-making. The setting in which a decision is made is another important factor in the decision-making process. Artificial intelligence (AI) systems are used by employee in modern workplaces to augment and automate decision-making. In this study, the influence of AI systems on decision-making is investigated. A thorough literature evaluation served as the foundation for this study's design. Limitations and the scope of future research have been recognized based on gaps in the literature. A research framework has been created to uncover several elements influencing employee decision making based on these findings. Technological development, a data-driven culture, human trust, decision automation-augmentation, and workplace incentive all affect how employees make decisions. In addition, the study was conducted in European countries by, Grossi (2021), the study aimed to analyze the impact of contextual factors of European hospitals on health decisions. The researcher conducted a systematic review that included 53 hospital directors from 9 European countries. The results indicated that organizational culture and leadership style are crucial factors. On the other hand, the study was conducted in Indonesia by, Feili et al. (2021), was aimed to identify the factors that affect the productivity of workers in hospitals. The researcher relied on a mixed approach, where the data was distributed in the form of sample questionnaires, then120 health workers. The results indicated that leaders' decisions are related to available financial resources. In Romania the study was examined how certain aspects of power structures in public hospitals influence how clinical services managers use accounting information tools to guide their decisions by Da Silva et al. (2018) a power Seven hypotheses about variables that may affect how accounting information tools are used by decision makers were examined. The results indicated that the use of more senior physicians for accounting information tools in decision-making processes was positively affected by their transformational leadership styles. The results also showed that it was experience, not rank, that determined a manager's level of power. On the other hand. the study was conducted in Turkey by Omarli (2017), the study's objectives are to provide a summary of the current state of research in the administrative decision-making process, identify the variables that affect it, and provide an integrated framework. The literature review was used to investigate the article that deals with the decision-making process. Following a review of the research, the factors influencing management decision-making are divided into 14 three categories: personal, psychological, and environmental. Locally astudy was conducted in Gasa strip by Alsaqqa & Akyürek (2021), its descriptive study and the data was collected throw a questionnaire in Gaza hospitals. The aim was to evaluate the organizational culture and leadership styles in Gaza hospitals on a sample of 45 health managers and consultants. The results indicated that Decisions depend heavily on the influence of policy and financial management. The study was conducted by Malfait et al. (2016) on three hospitals that used stakeholder committees for decision-making and were subjected to a retrospective examination of their decision-making procedures. The results showed that fifteen issues were discussed in stakeholder committees, and that 11 of these topics significantly changed the way decisions were made. The outcomes also were showed that each institution modified the theoretical model rather than applying it as it had been originally established. The outcomes also showed that hospital decision-making processes differed. At the operational level, stakeholders have a positive impact on all hospitals. Three elements—close connection with the board of executive directors, inclusion of themes of a practical and patient-oriented character, and decision-making at lower levels of the organization—can be identified as success factors as a result of variances in decision-making procedures. The study's was conducted by truglio et al. (2012), the goal was to compile all of the information on internal and external factors that affect adult patients' and healthcare professionals' decision-making. The methodological excellence of research publications was assessed by the Joanna Briggs Institute in (USA). According to the study, eight studies were used in this review. Based on commonality of meaning, the reliability rating of the categorical or reliable assessment was afterwards categorized from these investigations into 11 Categories. Three synthetic categories were produced by these Patient-centered care, closing the knowledge gap, and decision-making characteristics have an impact on the outcomes of collaborative decision-making. In addition, the study was conducted by Simmonds et al. (2012) a purposive sample of 19 healthcare workers, two hospitals for acute cases, and ambulance services were chosen for a qualitative in England. The goal of the study was to pinpoint the factors that influence decision-making for professionals. Individual interviews were used to gather data, which were then objectively examined using a comparative methodology 15 and evidence-based analysis. The study found that, in addition to expenses, inadequate information checking, culture, and the importance of peer support, the absence of around-the-clock care is one of the most significant variables influencing professionals' decision-making. The study was conducted by alsulamy et al. (2021) aims to clarify the opinions of medical experts on applying the concept of joint decision-making between patient and doctor in primary health care facilities in the Kingdom of Saudi Arabia. Purposive sampling and snowball methods were used to select the study sample, which included 16 health experts working in primary health care facilities. The study relied on a qualitative approach, which consisted of conducting semi-regular interviews with workers in the medical field. These interviews were recorded and converted into written texts, then translated and analyzed objectively using the COM-B trait classification model. The results showed that there were six main axes and 14 sub-themes that were extracted from the data. The main themes included patient-physician communication, patient-physician preferences, environmental context and resources, and professional aspects related to the patient and health. The results also emphasized the importance of building a relationship based on trust between the doctor and the patient by enhancing effective communication skills, which contributes to improving the quality of health care. While, the study was conducted by barasi (2015) aimed at Benghazi hospitals and general medical institutions to understand the nature of the relationship between organizational development and the effectiveness of administrative decision-making. It also attempted to ascertain the degree to which there are statistically significant differences between demographic characteristics (gender, educational attainment, years of service, and hospital name) and the factors affecting decision-making. 118 managers were given a questionnaire as part of a cross-sectional study using the stratified sampling technique, and the data were analyzed using SPSS. The organizational and management choices made in hospitals and medical facilities are effective In addition, all domains of development had a strong and statistically significant relationship with each other. The study also revealed that the variables (type) and (hospital name) caused statistically significant differences in the respondents' responses regarding organizational development and the efficiency of administrative decision-making, while the variables years of service and educational level did not cause any differences. 16 The study was conducted by Ghorbanzadeh et al. (2022) aimed to explore the experiences and perspectives of physicians and nurses regarding the decision-making process when transferring patients from the intensive care unit to the general ward. The study methodology was qualitative based on a purposive sample of six nurses and six physicians in government teaching hospitals. Data were collected from July 2018 to January 2019 through a semi-structured interview. Data were collected from July 2018 to January 2019 through a semi-structured interview. The results indicated that there are six themes that reflect the factors influencing the decision-making process when patients are transferred from the intensive care unit to the general ward: emergency decision-making, risky decision-making, lack of coherence in group decision-making, differences in clinical judgment, legal and ethical responsibility, and the absence of clear standards. The study was conducted by Badour et al. (2015). The study aims to examine the environmental and organizational factors that affect the decision-making process of administrators working in 36 different hospitals in the province of Ankara, and how these factors influence the decision-making process. Additionally, the study seeks to identify and analyze the potential variables involved in the decision-making process.Within the scope of this study, questionnaires were distributed to 160 administrators from 36 hospitals. Among these administrators, 30 were senior administrators (e.g., general director, deputy director general), and 130 were unit administrators (e.g., chief physician, head nurse, administrators of financial and administrative affairs). A statistical software program was used to analyze the collected data. A t-test was employed to assess the decision-making process and the environmental and organizational factors affecting it. The reliability of the factors was determined using the Cronbach Alpha coefficient, and the relationship between the factors was examined through correlation analysis. Additionally, regression analysis was used to test the research hypotheses. on the other wise the study was conducted by Kavosi et al. (2018) the study aimed identify the main variables that affect decision-making related to outsourcing in the health services sector. The researcher used the collaborative research approach. The study relied on a collaborative research approach, where relevant literature was reviewed in order to identify the variables influencing the outsourcing decision. The Delphi Technique was also used, relying on a committee of experts to reach consensus 17 on the most important influencing variables. The study tool was review of previous literature Review of scientific literature. Use a panel of experts. Application of Delphi technique. the study sample was selected in a purposeful manner. The results indicated that 180 factors affecting managerial decision making were extracted from the selected articles. 29 sub-variables were identified as the most important factors influencing outsourcing, and were organized into 6 main factors: strategy, quality, and management. Technology, performance advantage. The results of the Delphi method revealed that 22 sub variables had greater importance when making health services outsourcing decisions. 1.9 Gap of literature review Based on the discussion of previous studies, several knowledge gaps can be identified regarding the factors influencing administrative decision-making, including a lack of evidence-based studies in local cultural contexts. While numerous studies have been published on shared decision-making in various global settings, few specifically address the local cultural context. Additionally, although "environmental context and resources" have been acknowledged as important variables in some studies, little attention has been paid to improving healthcare resources or making environmental adjustments to facilitate shared decision-making. Another gap is the sparse research linking the skill of effective communication between physicians and patients. Despite its recognized importance, no studies offer concrete suggestions for improving this skill, particularly for practitioners in primary healthcare systems. Furthermore, experimental studies investigating the effects of shared decision-making on patient outcomes are scarce. Most existing research relies on qualitative methods like interviews, with few experimental studies quantifying the impact of shared decision-making on patient satisfaction and treatment quality. The role of technology in shared decision-making also remains unclear. Although technology's role in healthcare is growing, there is limited exploration of how digital tools applied to health outcomes can facilitate shared decision-making. Finally, there is a lack of literature discussing the economic aspects of shared decision-making. Little information is available regarding the costs associated with implementing such frameworks or the potential economic impacts on health policy-making and planning decisions. 18 Chapter Two The Methodology In this chapter, methods that were used to answer the study objective are presented in details. This reflects on study design, study setting, participants, used tool, study sample and sampling technique. 2.1 Study design Research approach: The study relied on a qualitative approach to explore the factors influencing managerial decision-making. This approach focuses on human interaction and understanding depth and context from the participants' perspective. 2.2 Study Setting Associated with the Ministry of Health in 2023 accounted for 56.7% of all hospital beds in Palestine. There are 18 hospitals run by the Ministry of Health in the West Bank, with a total bed capacity of 1.898, or 44.3% of all hospital beds in the West Bank (Ministry of Health, 2023). There are 13 hospitals run by the Ministry of Health in the Gaza Strip, with a total bed capacity of 2.011, accounting for 77.0% of all hospital beds there. The study was conducted six governmental hospitals in the northern West Bank affiliated with the Ministry of Health, including (Rafidia Hospital in Nablus, Al-Watani Hospital in Nablus, Khalil Suleiman Hospital in Jenin, Tubas Turkish Hospital in Tubas, Thabet Thabet Hospital in Tulkarm and Khalil Nazzal Hospital in Qalqilyaand salfeet hospital) 2.3 Study population The study population consisted of 30 potential participants from the managerial directors and department heads of government hospitals in the northern West Bank. However, only 15 participants were selected for interviews, based on the principle of data saturation. During the interview process and concurrent thematic -analysis, it became clear that the information and themes became repetitive and no new ideas emerged after the fifteenth interview, indicating that a state of cognitive saturation had been reached, which is a sufficient indicator to stop collecting further data in qualitative studies. 19 2.4 Study sample Participants in the study were selected using a purposive sampling method, carefully selected based on specific criteria to ensure their close connection to the study topic. The criteria used to select the sample were as follows: Geographic location, with managers working in hospitals located in the northern West Bank being selected. Job role: Administrators and managers holding leadership positions requiring daily or strategic decision-making were selected. Professional experience: Participants were required to have at least five years of practical experience in managerial or leadership roles. Consent to participate: Participants were selected if they voluntarily agreed to participate in the study. Given its objectives and procedures, sample characteristics were determined, with male and female participants selected to gain a general perspective, as well as participants from di verse age groups to cover different experiences, ensuring they had management or related qualifications. 2.5 Research approach 1. Nature of the Study: The study utilized an approach that was more thematical in detail, as it intended to access the many factors affecting management decision-making from the personal and real experiences of the participants. 2. Rationale for the Choice of a Qualitative Method: Later, how decision-making is complex and centered on people necessitates exploring different modes of perspectives and experiences. A qualitative approach provides in-depth and contextual knowledge that is true to the administrative realities in hospitals of northern West Bank. The need for raising new themes and a pattern arose through active interaction with the subjects: • Research Strategy. • Semi-Structured Interviews. 20 This tool was designed to gain findings that were rich and flexible in that it used open- ended questions for interlocutors to elaborate upon, with options for further probing when required. This method helps to uncover practices or patterns that tend to influence management's decision-making: • Steps of the Qualitative Approach: 1. Design Phase. 2. Establish the objectives for research and create research questions. 3. Draft an interview guide based on existing literature. • Data Collection: Conduct semi-structured interviews with administrators and managers in hospitals in Northern West Bank. Take consent from the participants in order to make a taping of the interviews. • Data Analysis: Thematic analysis is a systematic process used to understand the main patterns and themes that emerge in qualitative data, such as interviews or transcripts. When analyzing a study titled "Factors affecting patterns of managerial decision-making in governmental hospitals in the northern West Bank – Palestine, A qualitative study," the steps of thematic analysis can be followed as follows: First, read the data. The approach begins with a thorough review of all data gathered through interviews. The goal of this stage is to get a general sense of the reoccurring themes in the data. Second, initial coding: After examining the data, the researcher starts identifying words or phrases with pertinent meanings. These expressions may refer to elements that influence administrative decision-making in government hospitals. Third, identify initial themes: Using initial coding, we extract initial themes from the data. These themes may include internal variables like organizational policies, as well as external factors like social or economic pressures. At this point, the data can be categorized or coded to represent the numerous aspects that influence decision- making. Fourth, organize comparable themes: Similar or related topics are then 21 combined to build bigger themes that can capture the important impacts on managerial decision-making in government hospitals. Themes such as "leadership," "regulatory environment," and "economic factors" may be included. Fifth, in-depth topic analysis: Each theme is thoroughly examined to determine how it relates to other decision- making elements. Each subject is examined within the larger research framework to determine its impact on hospital management patterns. Sixth, Interpreting the Results: This phase involves interpreting and analyzing the identified themes and elements within the study framework. It examines how these elements influence decision-making methods in government hospitals in Palestine's northern West Bank, while also taking into account the region's cultural, social, and political environment. develop findings and make recommendations based on the thematic analysis of the key elements impacting administrative decision-making in government hospitals. Recommendations can also be made to improve future administrative processes. In this approach, thematic analysis becomes a powerful tool for extracting patterns and meanings from qualitative data, leading to deeper insights into research issues. One such tool is ANVIVO Tool. • Interpretation: Relate findings back to management theories while discussing the same in context to the previous literature. • Reporting Results: Results are reported in ways that reflect the participants' experiences and perspectives in their context. 2.6 Data collection methods Semi-structured interviews were chosen as the major data collecting approach due to its adaptability and depth in eliciting participants' viewpoints. Semi-structured interviews use a combination of predetermined open-ended questions and the ability to enquire further based on the participants' replies. This gives the researcher insight while also providing framework for addressing study objectives. The resulting rich qualitative data aimed to capture the complexities of decision-making processes in an administrative setting: 22 a. Interview guide: • The interview guide was designed based on a review of relevant literature and in line with the study's research questions. • These open-ended questions focus on: The factors that influence managerial decision making. • The most prominent of these factors were political factors, financial resources, patterns, and their impact on administrative decision-making. • An interview guide was developed based on the review of the literature. • Each of the participants was interviewed in private and comfortable surroundings. • Interviews were recorded with the consent of the respondents and supplemented with field notes. b. Supplementary Data Collection Method: Alongside interviewers, document review was utilized as an additional data collection technique to supplement the understanding of the organizational context. c. Supporting Tools for Data Collection: In light of data collection, some subtle but sure tactics are to be used to ensure the accuracy and depth of information: 1. Audio Recording: All interviews were audio-recorded to capture precise responses to ensure full veracity so no information was lost through transcribing. 2. Field Notes: Field notes were compiled alongside the detailed records of interviews, capturing explicit non-verbal cues for later depth in the analysis. 2.6.1 Types of Interviews Interviews have several forms and types that can be classified as follows: • Unstructured interviews: Interviews that are performed with little to no interview questions. They frequently proceed in a manner akin to a typical conversation, with the exception that they are focused on the subject of the study being reviewed. Researchers employ this rather unstructured interviews style to build rapport and comfort with participants; it is particularly helpful when discussing delicate subjects. In order to get as much detailed and comprehensive information as possible, the researcher is expected to survey participants. The lack of a set interview protocol and 23 the tendency for participant narratives to sidetrack the discussion from other facets of the research question you need to address are two drawbacks of this kind of interviewing. • Semi-structured interviews: interviews in which the researcher is assisted in conducting the interview by means of an interview protocol. Although some elements of a conversation may be included, the majority of this is a directed discussion between the participant and the researcher. Although it retains some structure—hence the term semi-structured—it also gives the researcher the opportunity to look over the participant for more information. Selecting an interview method gives the researcher a great deal of flexibility. Because the unique interview procedure for the research will keep you focused on getting all the information you need to answer the research question, conducting many rounds of interviews is not necessary. More research is necessary for this kind of interview in order to get more specifics about the ideas, sentiments, and opinions of the participants. • Structured interviews: These are the interviews where the researcher strictly follows the interview protocol. Only the questions on the interview protocol are asked, making it a more formal interview format. As a result, there are few possibilities to delve deeper into and discuss subjects that interviewees bring up in their responses. This approach helps focus on the particular event or experience that the researcher is studying, therefore it can be useful when the researcher has a long list of interview questions. It speeds up the interview process and ensures you have the right information, so you shouldn't need to do follow-up interviews to any questions you missed or forgot to ask. 2.6.2 Procedures related to the interview The interview process was organized and systematic to permit proper collection of quality and reliable data, while maintaining ethical standards. The procedures are as follows: • Preparation Stage. • Interview Guide Development. An interview guide was developed following the study objectives and a review of the relevant literature. 24 The questions were semi structured to permit detailed disclosures by the interviewee and, at the same time, ensure coverage of all important themes. • Sample questions include: What is a decision-making crisis, that you recently faced? What do you consider the most important factors in making decisions? In what way do organizations' policies and environments influence your decisions? • Ethical Approvals: Ethical approvals were obtained from the institutional review board (IRB) or ethics committee. - Consent forms were prepared that clearly delineated study objectives, voluntary nature of participation, and confidentiality issues. - Recruitment of Participants: Participants were purposely selected on the basis of their relevance to the research topic. An initial contact was made by either phone or email, clearly outlining the study and seeking willingness to participate in it. Suitable times and places were chosen to conduct the interviews according to the convenience of the participant(s). Conducting Interviews: • The Overview: • In opening of every interview, researchers: - Their name being disclosed, and the purpose for study being elaborated - The consent form with its contents was explained to the participant; the rights were listed such as a participant's right to withdraw at any time without penalty. - Get permission for audio-recording of the interview. 25 • Establishing Rapport: - Efforts were made to establish a comfortable environment to encourage open and honest communication. - Initial questions were intentionally non-threatening and, thus, general, to make a transition toward conversation easier. • Main Interview Process: - The researcher used an interview guide while allowing flexibility for the participant to depart and explore other emerging themes or unexpected responses. - Probing questions were used in encouragement to elaborate on responses e.g.; "Can you explain that further?" or "Why do you think that is?" - The interviews were held in private, quiet moments whenever possible, to afford anonymity and attend to minimize distractions. • Time Taken: A fairly reasonable view of time assigned to each interview ranged from 30 to 60 minutes, depending mainly on the circumstances of deeper sharing by a participant and the availability of the interviewee. 2.6.3 Post-Interview Procedures • Debriefing: - Participants were thanked for their time and contributions at the end of the interview. - Participants had a chance to clarify any remaining questions they had. - Participants were informed about the next steps of the research regarding how their data would be utilized and analyzed. • Transcription: - Careful verbatim transcription of the audio recording was done to capture data as soundly as possible. - The notes on any non-verbal responses (e.g., pauses, tone) were tagged when relevant. 26 • Validation: Transcripts were sent to participants in hard copy for review (member checking) to ensure their responses, as reported, had been accurately recorded and interpreted. • Data Storage: Audio recordings and transcripts were stored securely in encrypted files to maintain confidentiality. Consent forms were stored in a separate location from interview data, allowing for participant identities to remain undisclosed. Ethical Considerations: • Confidentiality: Identities were replaced with codes. Identifying information was dropped out for the transcripts. • Voluntary Participation: Participation was voluntary, with the assurance that a participant could withdraw from an interview for whatever reason without penalty. • Informed Consent: Participants were required to sign a consent form disclosing their understanding of the nature of the study and their willingness to participate. Challenges and Mitigation: Challenge: Within the interview, the participants would seem tentative regarding providing very sensitive information. Mitigation: This was done by building trust and assuring total confidentiality. Challenge: There could be an implicit bias during the interview. Mitigation: Neutral tone and the avoidance of leading questions were focused upon. 27 2.7 Working Plan In the first stage, the research questions were formulated, and based on this, qualitative tools were tested to choose the tool that could be appropriate and suitable for examining the research questions. In the second stage, the process of determining the location of the research community was carried out using the method of locating the hospitals that target the research sample. In the third stage, approval was obtained from the research department to interview the managers and then communicate with the study participants and obtain their approval. Fourth: Interviews were conducted with members of the research sample in a closed interview. The saturation stage in semi-structured interviews refers to the point at which the researcher stops collecting new and useful information through the interviews. When the researcher reaches this stage, he or she has collected enough data to achieve the stated objectives of the interview The sample size was 30 participants, 15 of whom were selected because the researcher reached data saturation and found that the ideas were repetitive.. This is due to the repetition of ideas and the cessation of new information, as the researcher no longer gains new insights. Or additional concepts that affect the breadth of the research. The researcher notices that responses begin to be similar across different participants. At this stage, the researcher has achieved the research objectives of the interview without the need to collect additional data. 2.8 Data Analysis Drop down formatting for each interview: Basically, the interviews were dissected into their main topics to facilitate logical analysis. The sequence comprised: • Interview ID: the identification of the participant. • Theme: the central topic being discussed (e.g., Political Factors, Financial Factors, Leadership Styles, etc.). • Sub-Theme: more microscopically regarding a particular aspect of the theme, such as political pressure or resource allocation. • Response: the verbatim response of the participant during the interview relating to the theme or sub-theme. 28 • Notes: Records of personal observations and insights that stem from analysis of the response. Transcription Steps: 1. Listening or Reviewing Raw Data: The raw interviews were intensively reviewed (either through audio recordings or as written transcripts) to come up with main points that were to be extracted. 2. Identifying Themes and Sub-Themes: Responses were arranged based on recurring topics or themes observed across the interviews. For instance: Political considering that in the participant said "political pressures" or "unstable environments." Financial, considering the constraints of resources or allocation budgets. 3. Summarizing Responses: To the widest extent allowed, that is, retaining the same meaning, responses from each of the participants were summarized. Example: Participant says, "The decisions more often follow along with political directives." Summarized: "Political directives challenge the independence of administrative decision-making." 4. Analytical Notes: oBased on just how the response fits into larger themes or patterns, analytical notes are added. oExample: To strengthen a case of participant mentioning financial hurdles over and over again, one would annotate a mark of factoriality. 5. Usage of NVivo or similar tools: Coding the Responses: Every response was given a "code"-showing the theme and sub-theme. For example: Code: Political Pressure. Theme: Political Factors. Aids in putting together similar responses for an analytical view. Theme Consolidation: Responses were analyzed as a pack in order to draw out dominating cons-spouse ideas: the frequency with which political or financial factors were mentioned. 6. Organization into Table Format: The data that was extracted were structured into a table for easy reference: 29 • Interview ID: Connects back to the original. • Themes/Sub-Themes: Grading of each session based on the relevant topics. • Response: A literal summary of what the research participants actually said. • Notes: Analytical insights based on the response. 7. Key Considerations During Transcription: • Accuracy: All possible efforts were made to ensure verbatim representation of participant responses, and mak?inain alteration in meanings. • Patterning: Concentration and amplification of common themes across several respondents to highlight vital considerations in decision-making. • Simplification: Full-length feedback was synthesized into concise bullet points. Example of One Interview Analysis: • Raw Response: "We are often under pressure to make decisions based on political directives rather than the needs of the hospital." • Thematic Unit: Political Factors. • Sub-Thematic Unit: Political Pressure. • Summarized Response: "Political directives inflict themselves upon the administrative independence of the decision-making process." Notes: This corroborates with the other interviews, highlighting the extent of political pressure exercised. Result of the Process:The result has been a neat table of interviews organized by themes and sub-themes, from which it is easier to analyze commonalities in respondent input. It further provides an imposing platform for discussion or further research based on the finding. 2.9 Generalizability Since this study is qualitative in nature, generalizability is not a goal. On the other hand, partial generalizability studies can be carried out in comparable settings. Those who require it, not the researcher, make this generalization. 30 2.10 Validity and Reliability Validity is the suitability of the explanations, analyses, and descriptions provided for the phenomenon being studied. In qualitative research with open-ended questions, it is measured primarily in terms of internal validity and generalizability. The researcher took care to apply this term in a trustworthy manner in this investigation. With relation to the population being studied, this application was articulated in terms of precisely identifying and characterizing the respondents as well as explaining the procedures and patterns included in the research questions that are rooted in the body of current knowledge. Establishing trust and presenting information in a straightforward and understandable manner are essential for doing research. Openness to feedback at every step of gathering, logging, presenting, and analyzing data. presenting the results with the authenticity and rigour of descriptive, interpretive and evaluative, rich and comprehensive. 2.11 Ethical Issues Before starting the research, participants were informed of the research and ensured that it would be for the purpose of scientific research and related research in general. Participants were informed of the general aim of the study (to explore the factors that influence the pattern of managerial decision-making in government hospitals) before making the decision to participate, and their written consent was obtained. A written consent form was prepared for the hospital managers who would participate, explained and read to them before they signed it. Furthermore, in order to maintain anonymity, pseudonyms were given to the participants. 2.12 Research contributions This study has many contributions. At the theoretical level, the results was show the most important factors that in turn affect the pattern of managerial decision-making in governmental hospitals in the northern West Bank, and its impact on their professional and daily lives. The current study has practical contributions. First, making informed decisions: Research may identify the main factors that influence administrative decision-making in public hospitals, the most important of which are political influences, financial resources and constraints, and leadership styles. Understanding these factors helps administrators make effective decisions, leading to improved overall 31 hospital management. Second: Policy implications: The research results can have implications for health care policies. Public hospitals often operate within specific regulatory frameworks, and insights from this research may lead to policy adjustments or improvements. 2.13 Translation The interviews were conducted in the same language as the participants who spoke the local Palestinian dialect (urban and rural). The audio interviews and data analysis were transcribed in the same language. All data were translated into English by paying an external translator. The two translated interviews were reviewed and compared with the original versions to ensure accuracy. 2.14 Reflexivity In qualitative research, reflexivity is the process of considering and analyzing the researcher's role, prejudices, presumptions, and impact on the investigation. It highlights the significance of self-awareness in influencing the research design, data collecting, and findings interpretation while acknowledging the subjectivity of the researcher. In qualitative research, where the researcher actively participates in the creation of knowledge, reflexivity is very important (Finlay, 2002). 2.15 Conclusion This chapter discussed the study procedures by clarifying the study methodology used and the study tool, which was the interview. This section also clarifies the study sample that was selected for conducting the interview. Furthermore, the researcher discusses in this chapter the preparation and execution of the interviews. 32 Chapter Three Result This chapter aims to provide a comprehensive analysis of the data collected from the 15 interviews conducted with administrative managers and technical managers working in hospitals in the northern West Bank. The questions were directed to explore the factors influencing managerial decision-making and to link these factors to participants’ demographic variables such as age, gender, level of education, and number of years of managerial experience. NVivo software was used to analyze qualitative data and extract recurring themes and patterns, which helped organize information and understand the challenges and factors that influence managerial decisions. 3.1 Socio demographic characteristic The result was indicated in Table (3.1) the distribution of demographic variables for study participants according to the following: • Gender: the percentage of female participants was 15%, while the percentage of male participants was 10% of the total sample. This distribution shows a relatively balanced representation of gender in the study. • Age: Participants aged 46-48 were the most represented, at 13.33%. While the percentage of participants between the ages of 49-52 years was about 11.67%. • Educational level: The vast majority of participants hold a bachelor's degree, at a rate of 21.67%. In contrast, there are only two participants who hold a master’s degree, with a percentage of 3.33%. • Years of experience: - Participants with administrative experience ranging between 5-7 years represented 11.76%. - While the percentage of participants who have more administrative experience (8- 12 years) is 13.33%. 33 Table 3.1 Socio demographic characteristic (n=15) Demographic Variable Category no Percentage Gender Female 9 15% Male 6 10.% Age (46-48) 8 13.33% 49-52 7 11.67% Level of education Bachelor's Degree 13 21.67% Master's Degree 2 3.33% Experience (5-7 years) 7 11.67% (8-12 years) 8 13.33% 3.2 The first question Do you think that demographic variables (gender, age, educational level, years of administrative service) and the extent of their impact on managerial decision-making. To answer this question, the researcher presented all of the participants’ answers to this Then, all the interviews were analyzed, and all sentences were simplified, codes were created, and then a theme was created and the sub theme was replaced. question as follows: Interview 1: Experience makes a big difference. While maturity plays a role, people tend to value hands-on field experience more than formal education. Interview 2: Administrative experience is crucial, but cultural factors often influence how much impact women leaders can have. Age and education also affect how staff accept leaders. Interview 3: Both experience and education are important, but cultural and political barriers often reduce their influence—especially for women leaders. Interview 4: Age and experience help build trust in decision-making. Education matters, but in urgent situations, it usually takes a backseat. Interview 5: In government hospitals, having extensive experience is seen as the most important factor for effective decision-making. 34 Interview 6: Leaders with age and experience tend to make more confident decisions, while education adds a theoretical perspective to their approach. Interview 7: Administrative experience is key to earning employees’ trust, but age also gives leaders more credibility and authority. Interview 8: Experience drives decision-making in hospitals, especially during crises. Age helps leaders handle complex situations with confidence. Interview 9: Age and experience complement each other in improving decision-making. However, cultural perceptions can sometimes limit how much influence women leaders have. Interview 10: Education lays the groundwork, but experience has a bigger impact on decision-making. Younger leaders often face challenges in earning trust, even if they’re capable. Interview 11: Age and experience lead to well-thought-out decisions, but institutional barriers often limit how much impact individuals can have. Politics can also overshadow technical expertise. Interview 12: While age and experience improve decision-making, technical expertise is often undervalued compared to administrative experience. Interview 13: Age and administrative experience are essential for managing crises, but technical contributions are often overlooked when decisions are made. Interview 14: Age and experience are critical in crisis management, but ignoring educational qualifications can sometimes lead to less effective decisions. Interview 15: Administrative experience is the most influential factor, and age boosts confidence when dealing with challenges. Unfortunately, younger leaders often face limitations due to perceptions rather than ability. In order to answer and analyze this question, a table of codes (themes and sub-themes) was created as shown in the table (3.2) 35 Table 3.2 Codes for Question 1 Theme Sub-Theme Example Experience Administrative experience Experience makes a significant difference. Experience Crisis management Experience is the main driver for decision- making in hospitals. Age Credibility Age helps build confidence in navigating complex situations. Age Perception-based limitations Younger leaders are often challenged in gaining trust. Education Theoretical perspective Education provides a foundation, but experience is more impactful. Education Undervaluation of education Undervaluing educational background leads to less effective decisions. Cultural and Gender Factors Cultural restrictions Cultural restrictions reduce the influence of women leaders. Cultural and Gender Factors Gender-related challenges Women face challenges in gaining influence due to cultural factors. 1. Explanation of the Code Table for Question 1 The code table for Question 1 organizes participants’ responses into main themes and sub-themes, offering a clear understanding of the key factors influencing managerial decision-making. It highlights how these factors are shaped by different demographic variables, making it easier to identify patterns and draw meaningful conclusions. 2. Themes and Sub-Themes Them Experience: Sub them Administrative Experience Here, participants acknowledged professional experience has an effect on decision making. They argue that leaders are able to appreciate situations differently and because of that, they make better decisions. Example From Interview 1: ‘Experience, makes a significant difference’ Decision making from experience is crucial in any profession, including education. Less informed choices would lead to poor performance and ultimately hinder achievements from students, especially in times of crisis. After all, the consequences usually start from bad decisions. Why do people do so? 36 Example From Interview 8: ‘Experience, is the key factor for any type of decision making in hospitals, more specifically, during issues related to management crises.’ *Crisis Management of complex issues verging on the borderline of More extreme inappropriate individual response. Them Age: Sub them Credibility The older you are, the more trust and authority a complex situation will require for a senior leader or executive. Example From Interview 7: ‘In any respect, age increases the credibility and authority of the decisions’ Perception based limitations :Often, younger leaders do find it difficult to command trust and respect from the employees even if they are able and competent. Example From Interview 10: ‘Younger leaders are often challenged in gaining trust despite competence’ Education. Theoretical Perspective: As with all other subjects, education is consider a necessary building block but is commonly regarded as subordinate to practical job experience. • Them Education Theoretical Perspective: Education, for instance, adds a management understanding, but it is always less important than working experience. Example: A quote from Interview 6: “Education adds a theoretical perspective, but I believe that experience carries more weight”. Capacity Underestimation of Education: In some cases, participants pointed out that the level and importance of decision making conducted by education are less considered than experience, and this could be harmful. Example: A quote from Interview 14: "Overlooking educational qualifications sometimes make people make poor decisions". 37 Cultural and Gender Factors: Cultural Restrictions: In more traditional/conservative contexts, the impact of women leaders is often neglected because of cultural traditions and restrictions. Example: A quote from Interview 9: “Cultural views may inhibit the impact of women leaders”. Gender Related Issues: Culturally initialized gender biases create hurdles for women who are trying to scale to managerial roles and have a say in decisions regarding control. Example: A quote from Interview 2: "Cultural views limit women's power". Finding: The responses show that experience and age have the most impact on the way a manager makes decisions. When focusing on administrative and crisis situations, experience is essential while age is appreciated for the authority and confidence it has. Still, younger leaders are often limited by perception. Education is important as a foundation but is less useful compared to practical experience. There are also cultural and gender-based barriers especially for women in leadership positions . In order to achieve these barriers overcome, there has to be the use of optimal and balanced decision making and education combined. 3.3 The second question Are there factors that affect managerial decision-making in government hospitals in the northern West Bank? Interview 1: In an unstable environment, decision making is heavily influenced by political factors. Management is routinely compelled to put political requirements before the needs of the hospital. Financial restrictions are also a key challenge to address, as often only limited options are available and creative responses are needed. Although democratic and participative leadership styles make a significant effort to build trust and support new ideas, in practice, authoritarian leadership dominates because of the challenges we face today. 38 Interview 2: Political factors are the most powerful, because of the enormous pressures acting on public hospitals. Transformational leadership can be used to motivate employees under these conditions [31,39,40]; however, financial limitations impede decision-making to a large extent, irrespective of whether the plans are considered good.[26] “With limited resources and pressing needs, accurate planning is a must.” Interview 3: Politics also dominates, and decisions are often enshrined by forces above the hospital itself, without adequate regard for its individualized needs. Hence administrative culture is preventing democratic leadership, which would enhance performance. Interview 4: “The hardest one of them all is really the financial pressure, given that most decisions come down to resources.” The politics of performance — which is a major aspect of participatory leadership — becomes difficult to achieve when resources are thin or when facing political head winds.” Interview 5: “Political factors, which priorities maybe not what the hospital needs, represent a major impediment. Transformational leadership may be the perfect answer to face these conflicts; in reality, we have to moderate with a much more cautious and more reserved leadership." Interview 6: "Financial “Financial pressures and political demands are interrelated challenges. Participative leadership helps foster collaboration, but is difficult to sustain with limited resources. Interview 7: “Political interference trumps decision priorities. Scarce resources also make it more challenging to implement. “The best collaborative leadership is also the most idealistic — and the least pragmatic.” Interview 8: “I should note that every decision is influenced by financial constraints and political priorities. “A leadership that supports innovation is vital and seldom done because of institutional cultures. Interview 9: “There are immense hurdles that come with political pressures and available resources. Participative leadership, the extent to which staff have input or the 39 ability to influence decisions, has the potential to empower staff but ultimately relies on on an inclusive environment." Interview 10: Financial constraints influence decisions, so you need to be creative and flexible. Transformational leadership convinces teams to surmount systemic limits.” Interview 11: “Political considerations define priorities, and financial constraints determine where decisions are viable. “The transformational leadership that enables innovation requires a culture shift." Interview 12: “Political pressures make decisions without a connection to actual needs. Creativity is the name of the game when it comes to financial symptoms. Progressive leadership is inclusive teamwork.” Interview 13: “Decisions are dictated by political imperatives. Budget constraints limit capacity-building efforts. Transformational leadership drives results, but without top management support.” Interview 14: “Freedom in decision-making does not exist due to political pressures and financial limitations. Participatory leadership encourages cross-departmental collaboration.” Interview 15: “The decisions are charged with political considerations, and there are few resources to draw on, which make planning more complex. The transformational leadership that inspires through adversity.” To analyses interviews 1-15, the NVivo software was used to analyses the texts received from 15 interviews with administrative and technical directors in hospitals in the northern West Bank. The analysis seeks to discover and relate factors that impact administrative decision-making to demographic indicators. The analysis was separated into four major components. 1. Political Factors 2. Financial considerations. 3. Leadership Styles 4. Administrative Experience 40 Appendix F explains how the interviews were analyzed and placed in the ANVIVO The results shown in Appendix F indicated the following: First: Political factors: The interviews indicated that political pressures and instability in the environment were primarily recurring themes, underscoring the significant influence of these elements on any administrative decision-making process. Second: Financial factors: The results confirmed that financial constraints are the biggest challenges facing all managers, which poses problems that require creative solutions to respond to them. Third, leadership styles: The results indicated that participatory and transformational leadership were mentioned as effective methods for improving institutional performance. Fourth, administrative experience: The results indicated that experience was a common element among all managers as a major factor in making informed decisions. Table 3.3 Keyword for Question 2 Analysis Category Keyword Example Political Factors Political pressures Political factors shape priorities. Political Factors Higher authority decisions Decisions imposed by higher authorities. Financial Constraints Limited resources Financial limitations dominate decisions. Financial Constraints Resource allocation Most decisions are tied to resource allocation. Leadership Sty