Transforming Pakistan’s hospitals: are high-performance work systems and ethical leadership the answer?
Creators: name: Faisal, Muhammad
Publisher: name: RMIT University
Year: 2024
Subjects: classificationCode: 350503
subject: Human resources management

description: Globally, public healthcare is under pressure to improve efficiency and effectiveness in providing high-quality healthcare within allocated budgets. The challenges facing healthcare in developing countries are exacerbated by high rates of poverty, rapid population growth and scarce resources. Based on the applications of social exchange and social learning theories, this thesis focused on the public healthcare sector in Pakistan and investigated the roles of contemporary human resource management (HRM) practices and ethical leadership (EL) in influencing employee attitudes and behaviours in two teaching tertiary care public hospitals in Lahore, Pakistan. In that respect, the thesis examined the extent to which high-performance work systems (HPWS) influenced employees’ affective commitment (AC) and organisational citizenship behaviour (OCB). Additionally, the thesis examined the mediation role of AC in the relationship between a) HPWS and OCB and b) EL and OCB. Finally, the thesis examined the moderating role of ethical leadership in several relationships between HPWS influenced AC and OCB. 

The study employed a case study research approach in which mixed methods were utilised to obtain the perspectives of both leaders and employees through qualitative and quantitative methods. The leadership perspective was based on semi-structured interviews and hospital documentation. Data included ten key informants from Peace Hospital (Case 1) and 12 key informants from Hope Hospital (Case 2) to develop an in-depth understanding of their leadership roles and the HRM practices in their hospitals. The data were analysed through thematic analysis. The themes were identified through the questions in the interview schedule and the literature review. Later, the employees’ perspectives were obtained through a large-scale survey of 266 front-line doctors and nurses from Peace Hospital and 548 front-line doctors and nurses from Hope Hospital. The survey obtained information on employees’ workplace experiences and perceptions related to HPWS, ethical leadership, AC, and OCB. The data were analysed using SPSS for descriptive and inferential analysis and AMOS for hypothesis testing while applying a structural equation modelling approach.

Four main themes emerged from the qualitative data analysis. The first theme highlighted the structure and practice of HRM in both hospitals. This theme had three sub-themes: recruitment and selection, training and development, performance appraisal and career development. The second theme was leadership and managerial challenges, using the lens of contemporary HRM practices (i.e., HPWS). This theme was also divided into three sub-themes: status differentials, information sharing and teamwork. The third theme was related to employee outcomes – attitudes and behaviour focusing on employees’ commitment and behaviours. The fourth theme was related to the leadership and managerial qualities of successful leaders. 

From the quantitative data analyses, several major substantive findings emerged. First, for Peace Hospital, an increase in employee perception of HPWS had a significant but negative impact on OCB. However, for Hope Hospital, an increase in employee perception of HPWS led to a positive and significant effect on OCB. Second, for both hospitals, affective commitment played a mediating role in improving the effect of HPWS on OCB. However, for Peace Hospital, the mediating effect of affective commitment on OCB transformed the negative effect of HPWS on OCB into a positive effect. Third, for Peace hospital, employee perception of ethical leadership moderated the mediating effect of affective commitment on the relationship between HPWS and OCB. On the contrary, for Hope hospital, employee perception of ethical leadership did not moderate the mediating effect of affective commitment on the relationship between HPWS and OCB. Fourth, for both hospitals, all four direct relationships between HPWS and affective commitment, ethical leadership and affective commitment, ethical leadership and OCB, and affective commitment and OCB showed a positive and significant effect. Finally, for both hospitals, affective commitment mediated the relationship between ethical leadership and OCB. 

Theoretically, this study offered new insights into the mechanisms through which HPWS and EL impact employees’ attitudes and behaviour within a public healthcare setting. Specifically, the study argues for the role of ethical leadership at the supervisory level for the effective implementation of HPWS. The study further explains how the interaction between high-performance work systems and ethical leadership influence employees’ attitudes and behaviour. To the best of the author’s knowledge, this study is one of the first to examine the moderated mediating effects of HPWS and ethical leadership on the relationship between affective commitment and OCB in a public healthcare sector of a developing country. Thus, it extends and contributes to the literature on HPWS and ethical leadership theory and consequently lays the ground for future research to explore these constructs in other developing countries.

In practical terms, this thesis offered several practical applications of the findings to the public health sector, particularly in the Punjab province. First, during the time of transition to improve public health outcomes, the Pakistani government could prioritise the development of HRM at all levels of the public health sector. Findings from this thesis suggested that contemporary HRM practices, such as HPWS, had the potential to improve the performance of employees and public hospitals in the country by influencing employees’ attitudes and behaviours. Moreover, supervisors with ethical leadership could be encouraged and promoted to leadership roles so that ethical behaviour could be instilled in front-line employees. These findings could also be useful when designing appropriate ethical leadership training programmes for public healthcare sector leaders. Through the understanding of how ethical leaders motivated their followers, managers would be able to enhance those attributes associated with leadership effectiveness and thus increase performance outcomes among public healthcare sector employees. 

Future research directions could consider whether, in addition to the role of ethical leadership established in this study, other leadership styles (such as authentic leadership, servant leadership, and transformational leadership) play a role in the attainment of the individual, team, and organisational outcomes within the public healthcare sector. For example, new case studies focusing on employees from different provinces with extended stakeholders, such as leaders from the Health Ministry and patients, could be considered. Further, future studies could use non-self-report measures and collect data from multiple sources such as supervisors and co-workers. Additionally, future research could focus on longitudinal and experimental designs to improve the credibility of the causality of these relationships. Lastly, the role of culture and contextual factors warrants further investigation in the field of HRM in developing countries.