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Keitaro's friends Shirai and Haitani also arrive at the Beach and try to convince Keitaro that Naru is in love with him. While Keitaro and Naru are having a private chat, Shirai and Haitani throw drinks cans at Keitaro, hitting him in the head. This causes Keitaro to fall over Naru in a compromising position, leading her to believe he was trying to take advantage of her drunken state. Naru runs into Seta, and uses him to make Keitaro jealous when everyone attends a local festival. At the end of the night Keitaro tries to apologize to Naru, but she mishears him due to a fireworks display and believes he is trying to blame her.

Due to Keitaro's inability to properly apologize to Naru, Shirai and Haitani apologize to her for their role in the misunderstanding between the two. As everyone prepares to leave the beach, Seta announces that he is leaving Sarah in the care of Hinata House. This causes Sarah to try and leave Naru and Keitaro on a deserted island, but her plan is foiled.

February 17, [22]. October 22, [23]. Keitaro gets two tickets from Shirai and Haitani for the opening event of a new amusement park, so he decides to ask Naru out on a date. However, things get complicated when the other residents at Hinata Inn start asking Keitaro to let them go with him. In the end, he ends up buying tickets for everyone to go. His plan fails, so he decides to ask Naru out again.

This time things go pretty well for them and afterwards they seem to get closer more and more. One day, Tama-chan gets lost and while Keitaro and the girls are looking for him, they ran into Otohime Mutsumi again. They learn that she's also aiming for Tokyo U again, and that she's also living in a house right beside Hinata Inn.

Since she's too clumsy to study by herself, Keitaro and Naru decide to form a study group with her. While autumn comes to an end, Naru discovers by looking at an old photo that Mutsumi knew Keitaro 15 years ago. She comes to the conclusion that Mutsumi is the girl Keitaro made the promise with, and on Christmas Eve she shows Keitaro the photo and tells him he and Mutsumi are destined to be together.

April 14, [24]. November 12, [25]. Japan only.

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Now that he knows Mutsumi was the girl he made the promise with 15 years ago, Keitaro isn't sure about whether or not he should be with her or with Naru. He then decides its too difficult to choose at the moment. Since exams are getting nearer, the three ronins start focusing on their studies more than before. After her house gets burned down, Mutsumi goes to live with Haruka on the 2nd floor of the tea house.

In order to relax a bit from the study, Mutsumi asks Keitaro on a date. To add even more tension, Mutsumi starts to remember about the time she lived at Hinata Inn 15 years, and also about a promise she made with a certain someone. It is at this moment that Naru tells Keitaro he should be with Mutsumi. However, Keitaro tries to tell her that he's actually in love with her, but Naru kisses him before he could finish. She then says there's only ten days left before the exam, that is , implying he should focus on studying.

Then, on the first day of exams, Mutsumi states that the promise she made 15 years ago was with a girl. That night, Naru and Keitaro start wondering if Naru is actually the girl he made the promise with. The second day of exams, Keitaro starts daydreaming about the recent events and reacts 5 minutes before the end of the exam, thinking that there's no chance now that he can pass. July 17, [26]. January 7, [27]. Or Are They? Believing not to have passed the exam for the umpteenth time, Keitaro decides to give up forever on Naru and Tokyo University and steals on a ship to flee.

By mistake, however, he ends on Pararakelse island, Hawaii, where he meets Professor Seta, who is being assisted in his excavations by a local young woman, Nyamo, which looks very much like Shinobu. Naru goes looking for him, even before knowing the results of the exam, and the other Hinata Inn girls discover that both ronins and Mutsumi have finally passed the exam, but have a few days to confirm the results, otherwise everything will be lost.

On the island, Keitaro, Naru and Nyamo are lost in the desert during an expedition, but they find a kind of earthly paradise where they spend a good time together. In the end, the girls find them after many adventures, Keitaro is informed of the results of the examination and they all begin a desperate race to get home in time.

October 17, [28]. March 11, [29]. Keitaro is finally a student at Tokyo University, but before starting the lessons he breaks his leg and he's forced to stay at home until summer. Finally he's able to confess his love to Naru, but she doesn't answer. Meanwhile Mokoto receives a visit from her older sister, Tsuruko, who wants to bring her home to make her inherit the dojo. Motoko, who feels she isn't ready for such a responsibility, pretends to be about to marry Keitaro to stay at Hinata House, but she is discovered and defeated in a duel by her sister.

To redeem herself, they confront once again: if she wins will be free to remain to Hinata Inn, otherwise she will really marry Keitaro. With the help of both Ketaro and Naru, she's finally able to meet the challenge in some way. Shinobu dreams one day to get herself to Tokyo University to be with Keitaro, but her grades are not the best, so Keitaro first offers himself to help her at studying and then fulfills her desire for a date together. While he's still waiting for Naru's answer, Keitaro and the girls discover that Haruka and Professor Seta had been in a relationship when they were young, and they still feel something for each other.

January 17, [30]. May 6, [31]. Mutsumi calls Keitaro and Naru on holiday at her home in Okinawa. The two are very shy in spite of their feelings, so Mutsumi promises to help her friend. But then she kisses Keitaro right in front of Naru. Falling from a tree, Mutsumi has amnesia that shows when she, Keitaro and Naru were children and played together to the Hinata Inn. Mutsumi also becomes seriously ill, and only a great joy could save her, so she asks Keitaro to marry her.

He agrees to stage the wedding, but everything seems all too real, and so Naru interrupts the ceremony. Mutsumi then challenge her to rock, paper, scissors with Keitaro as a prize for the winner, but in the end she loses on purpose. During this period, Naru remembers many things of their childhood.

For losing his first semester at Tokyo University, Keitaro decides to follow Professor Seta in the USA for six months and develop his passion for archaeology. April 17, [32]. June 10, [33]. Keitaro leaves for the USA, is seen off by the girls and especially Naru, and promises to return after six months. The expected time passes, and all are waiting for his return to the Hinata Inn, but they have a nasty surprise. In his place comes Kanako, Keitaro's sister, who has become the new manager in his absence.

Skilled in disguise, she will turn the house into an inn, and while doing so puts girls at a crossroads: either work there to pay for the room, or they can go. All except Naru seem to give up, but eventually return to their steps and the situation appears to be improving.

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Kanako, however, has a real love for her brother, and when she realizes that all the girls have a crush on him, the war between them begins again. Only Naru and Mutsumi are on her side and want to help her fix things. July 17, [34]. July 8, [35]. Keitaro has finally returned to the delight of everyone in the Hinata Inn. The affection that Kanako has for him bothers Keitaro, and he tries to clear things up between her and Naru, but due to a series of misunderstandings, he can't. The other girls have realized that Keitaro's love is only Naru, so they ask the girl to confess her feelings, but she is still insecure and decides to leave for a while, starting a trip to the north of Japan.

Keitaro and the rest of the girls chase her, while Kanako tries repeatedly to seduce her brother and make him forget Naru. The concept of performance has been discussed above. Even more important is the question as to whether one should examine discrete HR practices or employ a systematic HRM approach. In this study we follow the systems approach, as this was proven valuable in earlier studies [ 13 ]. In addition to conceptualization, there are also important measurement issues concerning HRM.

Does one measure HR policies at the company level for instance by asking HR managers or at the individual level practices as experienced by employees? Nishii and Wright [ 14 ] refined this issue by distinguishing among intended, actual and perceived HRM. This study focuses on perceived HRM, following the Thomas Theorem: if men define situations as real, they are real in their consequences [ 15 ]. Thus, if employees believe that specific HR practices are employed in the organization, they will act according to that belief. An important theoretical issue that has dominated the field in the last decade concerns the precise nature of the mechanism linking HRM and performance outcomes.

HR practices forge a psychological contract between employer and employee that in turn affects these perceptions and experiences. In this article, job satisfaction is used as a mediating variable linking HRM to various outcomes [ 17 , 18 ]. In the last two decades, several studies on HRM and performance have been conducted in the health care sector [ 19 , 20 ].

In their review of health care studies, Harris et al. Furthermore, many health care studies relate HRM to organizational and HR related outcomes [ 21 - 25 ]. However, studies focusing on financial outcomes - which have been extensively addressed in the private sector HRM literature - seem rather scarce. This study focuses on the Dutch care sector home care, nursing care and care homes. Its contribution concerns two elements discussed in the literature. First, we apply a multidimensional performance perspective, and we will therefore consider three outcome dimensions: financial, organizational and HR.

This is innovative because although many health care studies have analyzed care - an organizational outcome - and HR outcomes, financial indicators have received much less attention. Moreover, we are unaware of health care sector studies that have examined the relationship between HRM and these three outcome dimensions simultaneously.

Many studies use employee attitudes as an outcome variable. Using job satisfaction as indicator of employee attitudes, we will test whether this holds for all three outcome measures considered in this article. This leads to the following three hypotheses:. H1: job satisfaction mediates the relationship between HR practices and financial outcomes in health care organizations. H2: job satisfaction mediates the relationship between HR practices and organizational outcomes health care organizations.

H3: job satisfaction mediates the relationship between HR practices and HR outcomes in health care organizations. Before discussing our data, it is important to shortly describe the structure of the Dutch health care sector. In general, the Dutch health care system can be described as a mix of public and private provider agents, mainly based on public funding [ 26 ]. This research focuses on organizations that provide long-term care. This includes organizations providing home care, somatic care and psychogeriatric a care and is mainly financed using public funds.

Next to this, citizens also pay a relatively small private fee. A central explanation for the limited number of studies focusing on objective and multidimensional outcome data is that such data are difficult to collect. This benchmark was developed by ActiZ - an important Dutch employer association - in cooperation with PwC - for the period to The benchmark measures and compares the performance of three different health care sectors home care, nursing care and care homes and contains employee data, client data and financial performance data.

We analyzed the data gathered from autumn to autumn In total, organizations participated during this period. The data will be analyzed at the organizational level. Thus, data collected at the employee or client level will be aggregated. Other variables, such as financial performance indicators, do not need to be aggregated, as they are only available at the organizational level.

With respect to financial outcomes, we will consider the net margin. With respect to organizational outcomes, we will focus on client satisfaction, and absence due to sickness will be considered to capture HR outcomes. The measurement of HR practices is discussed below. First, most financial performance data on health care organizations are publicly available and based on annual reports.

We discussed this information with an accountant from PwC. Only the responses of employees with direct interactions with clients were used in our analysis job functions such as nursing, care, client-related domestic support and occupational therapy , due to their relationship with the organizational outcome client satisfaction. This resulted in a database of 48, employees.

Within this employee database, each question was answered by at least This is consistent with Dutch averages for employees in home care, nursing care and care homes, which is predominantly a female profession [ 27 ]. As age is subdivided into categories in our study, we could only say something about the predominant age category.

The CQi employs a stratified sampling method, through which an independent agency surveys a representative client sample for each organization.

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Three groups are constructed: home care clients, somatic care clients in nursing homes or care homes and psychogeriatric care clients in nursing homes or care homes. Home care clients are asked to complete a survey; somatic clients are interviewed using a survey as a guide. For psychogeriatric clients suffering from cognitive issues such as dementia , an authorized representative completes a survey.

To ensure the comparability of the employee data with the client and financial performance data, we only included organizations with information in all three databases. This resulted in a database with 85 organizations. The dataset constructed as described above has the potential to increase our understanding of the relationship among HR practices, job satisfaction and outcomes. However, it also has limitations. The data are not gathered with academic objectives in mind; instead, its primary goal is to be practically useful for the organizations involved.

This implies that items used in this study are only partly based on validated scales and existing theory. To determine the reliability of the scales, we have computed reliability statistics where possible. The employee questionnaire contains five indicators that are often used in HRM and performance research: training and development, performance related pay, teamwork, job design, and autonomy.

In the overview article by Harris et al. They stated that HR practices that should be adopted in HRM systems incorporate high performance work practices found to have had a positive effect on performance in other sectors the so-called best practices without derogating the specific health care context.

The first two indicators included by us are the most frequently used in research [ 12 ]. The other three also score relatively high on the list of the most common practices ranked 5, 10 and 11 [ 12 ]. Boselie et al. No single agreed, or fixed, list of HR practices or systems of practices exists to measure HRM [ 30 , 31 ]. Nevertheless, a certain consensus regarding the measurement of HRM has emerged in the academic literature on HRM and performance during the last decade.

More than half of the articles published after made use of AMO Ability, Motivation and Opportunity theory [ 30 ]. The underlying idea is that employees will perform well if they have the requisite abilities, when they are motivated and when they obtain the opportunity to profile themselves [ 32 ]. Lepak et al. These five HR practices are also regularly part of the measurement of HRM in health care studies [ 21 , 24 , 34 ].

Training and development was measured using three items. All standardized loadings were greater than. Teamwork was measured using two items. All standardized loadings were greater than 0. Correlation between the two items is. Job design was measured using three items. Four items were used to measure autonomy. As stated above, we followed the systems approach and therefore combined the five indicators into one HR system variable. As our analysis is at the organizational level, we aggregated the employee data. In this type of analysis, only variables with sufficient variance across organizations are included.

To determine whether the data could be aggregated, the intraclass correlation ICC was computed. Aggregation is permissible when the variance between groups is larger than the variance within groups. It is stated as a percentage:. The organizational outcome is measured by focusing on client satisfaction. Clients were asked about their satisfaction with the treatment they received. This indicator consists of five items. We must note that the Association of Client Quality only provides aggregated scales, partly because of privacy issues. Thus, the reliability statistics and ICC cannot be computed.

However, the robustness of the CQi - which is most often analyzed at the organizational level - shows that aggregation seems appropriate [ 25 , 26 ]. The HR outcome measure considered is absence due to sickness.


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Absence due to sickness can be considered a key HR outcome as the decision of employees to be absent affects the available human resources and is a critical success factor for the continuation of work processes within the organization for example, see [ 36 ]. Absenteeism due to sickness is calculated in percentages, using a standard formula developed by Vernet [ 37 ].

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These days are then summed and divided by the total number of working days. Maternity leave is excluded. This is calculated for the organization as a whole. Furthermore, we included diversity of care to determine whether the relationship among the variables differs for organizations employing a diverse set of care activities as supposed to more specialized organizations. It ranges from a minimum of one to a maximum of six as there are six different forms of care in our sample: hospital care, extramural residential care, extramural personal care, day activities, maternity care and youth care b.

SEM allows us to test the full conceptual model simultaneously. Furthermore, SEM allows us to simultaneously analyze the direct and indirect relationships among the independent and the dependent variables. Finally, SEM also enables us to compare different models [ 38 ]. As our hypotheses include mediation effects, we employed bootstrapping [ 39 ].

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This method estimates the parameters of a model and their standard errors strictly from the sample without reference to any theoretical sampling distribution. In our study, we created samples with replacement from the available observed sample. As perception variables are measured on various scales 1 to 5 or 1 to 4 , we recoded them into a 1 to 10 scale to ease interpretation. Client satisfaction is also quite high: 8. With respect to absence due to sickness, the average score is. Finally, the average value for the net margin was.

Furthermore, the correlations show that HR practices are related to the outcomes as expected. For instance, HR practices are positively and significantly related to client satisfaction. As some of the bivariate correlations are in the medium to high range, we conducted multicollinearity tests. The variance inflation factor VIF values were all well within the acceptable range, with the highest being 2. Thus, our results are not adversely affected by multicollinearity. The numerical scores on all lines indicate standardized regression coefficients beta , and the scores in brackets are the explained variance.

The overall model fit was tested using several indices. The model fit values were CMIN We can now discuss the hypotheses in detail. First, we tested the hypothesis that job satisfaction mediates the relationship between HR practices and financial outcomes in the Dutch care sector. We therefore reject the first hypothesis concerning a mediating effect.

This could imply that the effect of HR practices on financial performance is direct and not mediated by job satisfaction. The second hypothesis proposed that job satisfaction mediates the relationship between HR practices and organizational outcomes. The results show that this is indeed the case. Therefore, our second hypothesis is supported by the data.

Finally, we tested the hypothesis that job satisfaction mediates the relationship between HR practices and HR outcomes in the Dutch care sector. The results indeed show that the indirect relationship between HRM on the HRM outcome sick absenteeism is significant. Therefore, our third hypothesis is also supported by the data.

The final step in the analysis was the examination of the control variables. In organizations with more female employees, clients are more satisfied with the delivery of services. Moreover, the percentage absence due to sickness is lower in these organizations. With respect to age, the results show that absence due to sickness is higher in organizations in which the average age is relatively high.

Finally, the diversity of care is positively associated with absence due to sickness. In other words, organizations engaging in a diverse set of care activities have more absence due to sickness than more specialized organizations. Finally, model validity was achieved through cross-model validation. Camilleri [ 41 ] suggests pursuing cross-validation in three phases.

In the first phase, the data are divided into two data sets.

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In the second phase, SEM via path analysis that calculates the structural fit index measured by R 2 is conducted for both datasets. The third phase consists of examining the differences between the calculated structural fit indices obtained for each dataset. The extent of model validity is determined by the similarity in the variance accounted for by each dataset. As the differences in the explained variance are small, the cross-model validation provided satisfactory results.


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Results of cross-model validation showing R 2 for the three samples. The main contributions of this study to the literature on HRM and performance in the health care sector concerns the use of a multidimensional performance perspective. In this respect, we examined three different outcomes: financial net margin , organizational client satisfaction , and HR sickness absence.

The results confirm the basic notion that HRM and performance within the health care sector are linked. When organizations apply - according to their employees - more HR practices, this is associated with greater client satisfaction, less sickness absence, and a better net margin. With respect to organizational and HR outcomes, the hypotheses regarding the mediating effect of job satisfaction are confirmed. In this respect, our study showed that higher job satisfaction is associated with higher organizational performance.

More specifically, in line with the assumption, our research showed a positive association between employee satisfaction and customer satisfaction because if employees are satisfied with their jobs, they are likely to behave toward customers in ways that yield positive service experiences. A more extensive use of HR practices leads to more satisfied employees. Moreover, satisfied workers are less likely to call in sick than less satisfied workers.

HR practices are directly related to financial outcomes, although the explained variance is small. Furthermore, we found that job satisfaction does not mediate the relationship between HRM and net margin. As we mentioned in the introduction, financial outcomes are a distant outcome of HRM. In fact, the literature about strategic management informs us that organizations can use different strategies to achieve their objectives [ 43 ].

In addition to a high performance strategy, organizations can also employ a low cost strategy [ 44 ]. Organizations can follow various strategies to become financially successful. One possible strategy implies investing in employees, which will likely result in more satisfied employees.

Another strategy implies cutting costs, which will result in reduced investments in employees and most likely less satisfied employees. The finding that HRM has a direct effect on financial outcomes may be because a low cost strategy also implies the use of certain HR practices, for instance performance management. It can thus lead to financial success without positively affecting the satisfaction of employees. We conclude this article by presenting some limitations. An important limitation of this research - but also of many other studies in this area - is the hidden assumption that the same mix of HR practices will work for all organizations.

Therefore, the inclusion of HR strategy in research designs will be an important addendum. However, it also has some drawbacks.