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High-performance work practices High-

performance
and medical professionals’ work work practices

outcomes: the mediating effect of

perceived organizational support
Mohammad Rabiul Basher Rubel Received 15 May 2020
Revised 17 June 2020
Department of Management, Bangladesh University of Professionals, Dhaka, 18 July 2020
Bangladesh 26 August 2020
Accepted 3 September 2020
Daisy Mui Hung Kee
School of Management, Universiti Sains Malaysia, George Town, Malaysia, and
Nadia Newaz Rimi
Department of Management, Dhaka University, Dhaka, Bangladesh

Abstract
Purpose – In this research, we investigate the effect of high-performance work practices (HPWPs) on medical
professionals’ work outcomes through the mediating effect of perceived organizational support (POS).
Design/methodology/approach – The study analyzes the opinions of 218 medical doctors from private
hospitals in Bangladesh, employing Partial Least Square-Structural Equation Modeling (PLS-SEM).
Findings – We find that HPWPs enhance employee performance and POS and minimize turnover intention.
POS also has a substantial influence on both employee performance and turnover intention. Moreover, POS
finds a significant mediating effect on HPWPs and performance as well as HPWPs and turnover intention
relations.
Research limitations/implications – The current research focuses on medical doctors who are presently
working in private hospitals in Bangladesh.
Practical implications – First, the hospital would recognize the role of employee perceived HPWPs. Second,
they might understand how HPWPs would utilize and maintain employees effectively via POS that might
further improve the healthcare industry. Suggestions for future research indicate the models potential to
provide optimal workplace environments that can benefit organizations as well as improve employee
performance.
Originality/value – The study would provide a unique insight into the higher-order HPWPs system and its
effects on the health care organizations in developing country contexts like Bangladesh. This study also
extends the research on POS as a mediator between higher-order HPWPs and employee outcomes in the
organization.
Keywords High-performance work practices, Perceived organizational support, In-role performance,
Turnover intention, Hierarchical reflective model
Paper type Research paper

1. Introduction
The field of human resource management (HRM) is continuously discovering effective uses of
HR in executing business strategy, thus establishing a new milieu for the recognition of
human factors in organizations (Ogunyomi and Bruning, 2016; Ogbonnaya and Valizade,
2018). An understanding of how HRM affect the work outcomes of the employees to achieve

The authors are grateful to the anonymous referees of the journal for their extremely useful suggestions
Journal of Advances in
to improve the quality of the article. Management Research
Funding: The author(s) received no financial support for the research, authorship and/or publication © Emerald Publishing Limited
0972-7981
of this article. DOI 10.1108/JAMR-05-2020-0076
JAMR business success is essential because one of the goals of HRM aims to improve organizational
performance (Safavi and Karatepe, 2018; Rubel et al., 2018; Iqbal, 2019). Prior research
suggests that a strong HRM system is a critical success factor in ensuring the efficiency of the
work process within an organization as well as in attracting, managing and retaining their
talented employees (Ostroff and Bowen, 2016; Rubel et al., 2017; Singh et al., 2020). Ostroff and
Bowen (2016) call for future study to investigate the HRM system strength, as it remains
largely underexplored. Furthermore, HRM researchers have argued for further examinations
on evaluating the role of employee perceived HRM practices in determining their impact at
the employee level (Kehoe and Wright, 2013; Rubel et al., 2018).
We, therefore, heed the calls by investigating the role of employee perceived high-
performance work practices (HPWPs), a strong performance-focused HRM system, arguing
that HPWPs have a more significant impact on employee outcomes. We argue that any
individual HRM practice may be limited in its capacity to influence employee outcomes.
However, HRM practices in a system are more likely to have a synergistic effect on employee
outcomes. We conceptualize HPWPs, a configuration of coherent practices to represent HRM
system designed to improve and sustain the value of employee performance, reflected into
five key elements, namely, participation, training and development, performance appraisal,
career development opportunities and compensation.

1.1 The rationale of the study

Following the logic that multiple complementary HRM practices are more likely to affect
employee outcomes, we propose that HPWPs would support desired employee behaviors
when its components are complementary and coherent, such that they mutually reinforce one
another toward the same end. In this research, we seek to advance research on HPWPs in the
context of a hierarchical reflective construct model. Edwards (2001) argues that a construct
can be presented in a hierarchical model that would be reflected in some dimensions. Here,
HPWPs are reflected by five mutually reinforcing HRM practices. Traditionally, HRM is
viewed as a multidimensional or unidimensional construct (Cooke et al., 2019; Hee and Jing,
2018). The unidimensional construct limits the understanding of the individual HRM
practices in a broader sense. While the multidimensional construct explains the individual
HRM practices yet ignoring HRM as a whole system (Rubel et al., 2018). We represent HPWPs
as a system reflected by five mutually reinforcing HRM practices in a hierarchical model, not
the combination of HRM practices. We argue that the mix of practices as a system would act
in synergy to generate more positive outcomes than those which are estimated from the single
HRM practices. However, the nature of the evidence for a synergetic effect of overall HPWPs
is limited. We are focusing on HPWPs as a whole system rather than a construct having
multiple HRM practices or unidimensional HRM.
Second, previous studies have systematically examined the effect of HPWPs on employee
outcomes. HRM researchers are trying to examine HRM system strength’s impact on service
employee performance (Rubel et al., 2018); hence, what the dimensions of HPWPs are, and
whether the use of HPWPs to promote employee outcomes in the hospitality sector as well as
the healthcare industry is remained unclear (Bartram and Dowling, 2013; Murphy et al., 2018).
In this regard, measuring healthcare professionals’ perceptions and their outcomes are
critical as well (Ang et al., 2013; Kloutsiniotis and Mihail, 2017). As such, our study provides
some insights into employees’ perceived HPWPs in shaping health professionals’ work
outcomes (job performance and turnover intention). So, our study is particularly important
given that past research has empirically focused on employees in general. We focus on
medical doctors from private hospitals who play an important role in delivering health care to
the public. Indeed, research supports the notion that medical doctors gather new information
and knowledge that can be used for innovation. Medical doctors are difficult to reach and High-
follow, especially over time, which makes their activities difficult to track. Our study analyzes performance
how medical doctors work and infer the causes of their effectiveness. We argue that the view
of medical doctors offers more explanatory power as the tangible success of a private hospital
work practices
is much affected by medical doctors’ performance.
Third, we contend that the HPWPs would not be solely responsible for employee
outcomes. We also claim that HPWPs would indirectly affect employee outcomes via
perceived organizational support (POS). This mechanism is especially important in that it
would determine whether and how HPWPs influence employee outcomes. We propose that
POS would convey the indirect effect of HPWPs on employee outcomes. To the best of our
knowledge, there is a paucity of research in the area of HPWPs under hierarchical modeling
with the mediation effect of POS on employee outcomes.
Fourth, like the global call for HRM study in health care organizations (Roy et al., 2017;
Schopman et al., 2017), such a study is also felt important in Bangladesh. It is evident that the
performance of healthcare employees is not up to the mark that is seriously pressurizing the
attainment of health-related millennium development goals (Alam and Shahi, 2012). A recent
study carried out by Mone et al. (2019) reveals that Bangladeshi female medical doctors are
not getting support in their jobs, which in turn affect their work lives. In a local study, Joarder
et al. (2018) find healthcare employees have low job satisfaction that acts as the main predictor
of their unusual behavior such as absenteeism, low performance, lateness, low commitment,
turnover intention and actual turnover. Rubel and Kee (2015) and Roy et al. (2017) report that
the healthcare employees’ turnover rate in Bangladesh is approximately 15%. Our study
advances HPWPs literature by explaining and providing evidence of how medical doctors’
behaviors are affected by HPWPs and POS in a developing country context. In the line of a
few existing HRM studies in hospitals (Matsumoto, 2019; Wilkinson et al., 2019), the current
research might be an addition.
Hence, tying the threads of previous research, this study explores the role of HPWPs on
health professionals’ performance and turnover intention via POS in hospitals in Bangladesh.
Though the importance of HRM for health is recognized, what effect HPWPs might have and
what can be done to strengthen health employees’ behavioral intention as well as actual
behavior have so far not received as much attention as the subject merits. In addition,
Bangladesh, a developing country, experiences a lack of study analyzing healthcare
employee turnover intention and performance with HPWPs. The current study expects to
discourse these unattended gaps.

1.2 Social exchange theory

Employment relationship involves a series of interactions between employees and employer
in the form of exchanging some sort of benefits to each other continually. Such an
employment relationship is said to be built on social exchange theory (SET) supporting the
views of Blau (1964) and Emerson (1976). Blau (1964) recommends that SET works on the
belief that parties involved in an exchange relationship would trust one another, and they
might fulfill their mutual responsibilities. Emerson (1976) believes that a number of
exchanges of benefits occur in a mutually agreed continuing social exchange process to
strengthen the reciprocal relation. As such, Rubel et al. (2018) state that SET might be an
appropriate theoretical model to explain an employment relationship as both employees and
the employer trust one another in fulfilling as well as reciprocating their trustworthy long-
term relation.
Relying on SET, HRM scholars have revealed that organizations show their concern about
the well-being of employees through HRM and, thus, become trustworthy (Rubel et al., 2018).
In exchange, employees reciprocate by trusting the organization more when they experience
JAMR organizational support and kindness toward them through HRM (Rubel et al., 2017). As such,
SET suggests the existence of a two-way relationship of behavioral reinforcement. We
assume this with the fact that HPWPs are considered job resources that are made available to
employees to encourage their performance and reduce turnover intention within the
workplace. It is argued here that HPWPs work to enhance the employee-organization
exchange process in a mutual relationship as supposed in SET. Employees might view
HPWPs as an organizational support mechanism to increase both employee and
organizational performance and, thus, getting recognition of their value-added
contribution to organizational achievement. Grounded on the exchange norm, employees
reciprocate such organizational support and gratitude by demonstrating their honest feeling
and behaviors towards the organization. This provides an understanding of how an
organization delivers a performance-oriented work setting and supports to encourage
employees to perform more and better continuously. We assume that employees would view
their organization more friendly and supportive and would repay the exchange relationship
with higher performance and retention in the organization.

1.3 Specifying HPWPs as a hierarchical reflective model

A higher-order or hierarchical construct in second-order is formed by more than one construct
in a first order, which is further presented by their indicators, thus creating two layers of
constructs (Hair et al., 2014). According to Hair and colleague, the primary purposes of
approaching a hierarchical model is to have highly correlated constructs and simple
structural model with a minimum number of relationships making the Partial Least Square
(PLS) path modeling easier to understand. The measurement model of the higher-order
modeling assesses the relationship between latent variables and their indicators (Hair et al.,
2017), which can be classified in two different types, such as reflective and formative. The
reflective model shows the indicators represent or reflect the constructs (Hair et al., 2017). Five
reflective indicators, namely, participation, training and development, performance
appraisal, career development opportunities and compensation, are used to represent
HPWPs in a hierarchical construct. These five HRM practices are assumed to be highly
correlated and mutually reinforcing as well as creating the HPWPs system. Figure 1 exhibits
the proposed research framework.

Figure 1.
A proposed research
framework
2. Literature review High-
2.1 In-role performance and turnover intention performance
Employee performance, a significant form of work outcome of employees, is the ultimate
return from the employees that each organization strives for and aspire to maximize (Atatsi
work practices
et al., 2019). Employee performance is defined as the entire direct and indirect employee
behaviors added to organizational achievement (Rubel and Kee, 2013). Early researchers
have unveiled its importance and relevance with organizational outcomes and success
(Sonnentag and Frese, 2003). Usually, employees engage in two types of performance: in-role
and extra-role performance (Schreurs et al., 2012). In-role or task performance is formally
required work behaviors that are directly linked to organizational goal attainment
(Motowidlo and Van Scotter, 1994). Putting in another way, in-role performance requires
employee’s effective functioning directly contributing to organizational objectives. In-role
performance is determined by the individual’s ability to fulfill their job requirements. This is
contrasted against extra-role performance, whereby employees go above and beyond their
role descriptions to achieve their workplace goals.
Extra-role or citizenship performance refers to employees’ discretionary and voluntary
behaviors that are not directly impacting employees’ required job behaviors but indirectly
promote the proper functioning of an organization (Podsakoff and MacKenzie, 1994). Helping
colleagues with extra workloads or spending extra time in volunteering orienting new
colleague might be the examples of extra-role performance. Extra-role performance is viewed
as a group-level outcome influencing team performance (Tjosvold et al., 2003), whereas in-role
performance measures individual achievement. It is assumed that since employees are
obligated to perform goal-directed behavior for which they are employed, they are more
concerned with their assigned or in-role performance than their voluntary or extra-role
performance. Considering this fact, the present study intends to examine health
professionals’ in-role or task-required performance.
Furthermore, the other outcome variable of this research is employee turnover intention
that might lead to actual turnover. Employee turnover is a costly and alarming fact because of
its undesirable effects on the organization (Rubel et al., 2017). Limyothin and Trichun (2012)
also support this view and reveal that turnover intention, as well as actual turnover, are more
likely to give rise to the economic problems of the organization. Yin-Fah et al. (2010) stipulate
that employee turnover influences employee-organization relationship unpleasantly.
Researchers have been extremely focusing on turnover intention to understand employee
turnover behavior (Rubel and Kee, 2013). Egan et al. (2004) describe that turnover intention is
the choice of employees to remain or leave the current workplace affected by the intensity of
achievement of expectations. Ali and Mehreen (2019) suggest that organizations can
minimize employee turnover intention through proper HRM measures. The present study
expects to investigate whether employee perceived HPWPs might influence health
professionals’ turnover intention.

2.2 High performance work practices (HPWPs)

Strategic HRM realm has pinpointed the characteristics of an optimal HRM system for
attaining organizational outcomes, focusing on the high-performance approach to HRM
(Kehoe and Wright, 2013). Accordingly, researchers have found that HPWPs, performance-
oriented HRM systems, affect organizational outcomes by shaping employee behaviors and
attitudes (Karatepe and Olugbade, 2016). More specifically, HPWPs enhance organizational
performance in work conditions that encourage employees to exert a higher level of effort to
accomplish organizational goals (Luna-Arocas and Camps, 2008). However, researchers have
argued over the concept of HPWPs, whether it should be unidimensional or
JAMR multidimensional. Some scholars opine that HPWPs include multiple and discrete practices
without any linkages (Obeidat et al., 2016). Nevertheless, prior scholars propose that discrete
practices are not sufficient enough to generate higher performance if they do not have any
dependence on each other (Delery and Shaw, 2001). Accordingly, HRM scholars suggest that
the elements should be multiple and mutually reinforcing (Kehoe and Wright, 2013).
Based on past HPWPs studies, the present study considers HPWPs as a reflection of a
comprehensive performance-focused HRM system with mutually underlying HRM practices
(participation, training and development, performance appraisal, career development
opportunities and compensation) to augment POS, employee performance and to reduce
employee turnover intentions in health organizations. Despite a growing interest in HRM of
health organizations, a resolution of the debate regarding the components or dimensions of
HRM has not been resolved (Ang et al., 2013). In this backdrop, the present study might shed
light on what might constitute HRM practices in the form of HPWPs in healthcare
organizations. The following table shows various dimensions of HPWPs in different times
from which present study HPWPs dimensions are being incorporated. Tables 1 and 2 show
early researches on HPWPs.
The application of HPWPs in the health sector is very limited (Ogbonnaya and Valizade,
2018). However, few researchers advocate the potentiality of a positive influence of HPWPs
on the attitudes and behaviors of employees in the health organization (Ang et al., 2013). In the
health sector, the effects of HPWPs have mainly been studied among physicians or nurses
and have been broadly tied with reduced worker health care errors, enhanced commitment
and satisfaction (Harmon et al., 2003; Roy et al., 2017). Bonias et al. (2010) consider HPWS to

HPWPs in other sectors

Authors HPWPs Attributes

Huselid (1995) Personnel hiring, performance appraisal, compensation, and training and
development
Pfeffer (1998) Job security, personnel hiring, decentralized decision making, compensation,
training and development, participation, and information sharing
Hoque (1999) Terms and conditions, recruitment and selection, job design, training, quality
issues, Communication and consultation and pay systems
Ashton and Sung (2002) Participation, compensation, performance appraisal, and information sharing
Horgan and Muhlau Training and development, incentives, selection, guidance and information
(2006) sharing
Pare and Tremblay Recognition, empowerment, compensation, competency development, and
(2007) information sharing
Luna-Arocas and Camps Salary, job enrichment, and stability
(2008)
Liao et al. (2009) Training and development, information sharing, participation, compensation, job
design, performance appraisal
Tang and Tang (2012) Selection policies, Training, performance appraisal, compensation, participation
and empowerment
Rubel and Kee (2013) Staffing, training and development, compensation, employment security,
performance appraisal, and career development opportunity
Pittino et al. (2016) Selective staffing, intensive training, career development, compensation and
benefits, performance appraisals, and employee participation
DeGeest et al. (2018) Stock option, bonus program and flex-time program
Jeong and Shin (2019) Job rotation, temporary project work team, self-managed work team, opportunity
for doing self-initiated projects, training emphasis toward on-the-job experiences,
Table 1. coaching, rewards for sharing learning experiences, and opportunity for
Dimensions of HPWPs participation in problem solving
in previous research Cooke et al. (2019) Rewards, training and development, performance management and Participation
 HPWPs in health Care sector
High-
Authors HPWPs Attributes performance
work practices
Harmon et al. (2003) Compensation, alignment, information sharing, participation, empowerment,
teamwork, career development, trust, creativity, and performance appraisal
Rodwell and Teo (2004) Elective staffing, comprehensive training, performance appraisal and equitable
reward systems
Pearson et al. (2008) Team-based work practices and compensation
Bonias et al. (2010) Employment security, selective staffing, training and development, self-managed
team and decentralized decision making, information sharing, career
development
Chuang et al. (2012) Supervisor support, team-based work, and flexible work arrangement
Baluch et al. (2013) Communication, supervisor support, performance appraisal and career
development
Fan et al. (2014) Necessary knowledge and skills. Adequate incentives and necessary support and
opportunities for expression
Kloutsiniotis and Mihail Recruitment and selection, training and development, employee autonomy, Table 2.
(2017) participation in decision-making, employment security, job clarity and Dimensions of HPWPs
performance management in previous research

measure the quality of patient care. Chuang et al. (2012) find the effect of HPWPs on frontline
employee job satisfaction and perceived quality of healthcare. We examine how HPWPs
affect medical doctors’ in-role performance and turnover intention.

2.3 Perceived organizational support

POS is viewed as a construct to explain how employees view their relationship with the
organization (Shore et al., 2012). Eisenberger et al. (1986) define POS as employees’ general
perception regarding the extent to which their organization values their contribution and
cares about their well-being. Employees develop their understandings of organizational
support as they experience organizational practices and processes to influence their different
tangible and intangible outcomes in a conventional exchange system (Eisenberger et al.,
2001). POS is employees’ inner feelings that their organization takes care of them, recognizes
their importance and gives value to their performance and thereby extends its helping
attitudes to fulfill their socio-emotional needs and well-being (Rhoades and Eisenberger,
2002). The norms of reciprocity suggest that an individual having POS gets socio-emotional
strengths from an organization making that individual value and trust the organization
(Karatepe, 2012). As such, on the one hand, POS incorporates such inner characteristics that
might stimulate employee behaviors that facilitate organizational achievement (Afsar and
Badir, 2017). On the other hand, POS signals the employees that the organization welcomes
and accepts them as members of the organization and fulfills their affiliation need by showing
them respect and recognition that ultimately contributes to their higher levels of well-being
(Caesens et al., 2017).

3. Hypotheses development
3.1 HPWPs and employee outcomes
The study on HPWPs and employee performance has attained much research attention.
Ogbonnaya and Valizade (2018) report a significant positive relationship between HPWPs
and the performance of both employees and organizations. Caliskan (2010) recommends that
HR practice enhances the value-added capacity of employees in the organization. Hee and
JAMR Jing (2018) conduct individual-level research in Malaysia and find a positive relationship
between two dimensions of HRM practices (performance appraisal ad training and
development) and employee performance. Arefin et al. (2015a, b) show a significant
positive influence of HPWPs on proactive employee behavior in the manufacturing
organizations of Bangladesh. In another study, Safavi and Karatepe (2018) also find a
significant linkage between HPWPs and employee creative performance and extra-role
performance in the hotel industry in Iran. In the context of health organizations, Harmon et al.
(2003) recognize that HPWPs, employee satisfaction and performance are significantly
related. Furthermore, Preuss (2003) shows that HPWPs can improve employee capacity to
healthcare by reducing the number of medication errors. Bonias et al. (2010) find a positive
relationship between HPWPs and high-quality patient care. Based on the above literature, the
following hypothesis is proposed:
H1. Employee perceived HPWPs is positively related to employee in-role performance.
Keeping valued employees in the organization is favorable to incurring the cost of staffing
again and again (Chowhan, 2016). Employee retention is also proved to be significant for
hospital performance as well (Scanlan and Still, 2019). For this purpose, research’s has proved
HPWPs as significant retention strategies for the organizations. Luna-Arocas and Camps
(2008) find a significant relationship between HPWPs and turnover intention in different
organizational settings and reveal that well-structured HRM practices can shape employees’
behavior and encourage them to be more organization-oriented. Harley et al. (2007) have
confirmed the positive influences of HPWPs on job satisfaction and retention intention
among eldercare employees in Australia. Baluch et al. (2013) find that employees’ perception
of HRM practices negatively affect their intention to leave. Karatepe and Vatankhah (2014)
reveal that employees perceived HRM has a link with the intention to stay with the
organization. In another research, Nie et al. (2018) prove that nurses’ perceived socially
responsible HRM practices and their turnover intention are inversely related. Thus, centered
on previous findings, the following hypothesis can be considered:
H2. Employee perceived HPWPs is negatively related to employee turnover intention.

3.2 HPWPs and POS

The employee-organization relationship is further viewed as an inducement-contribution
relationship (Chiang et al., 2011). Accordingly, an organization adopts HPWPs to induce
employee involvement and performance to foster organizational performance (Huselid, 1995).
Therefore, employees might consider HPWPs as an avenue of organizational support. When
an organization recognizes employee contributions and respects them through HRM
practices, employees view the organization as supportive and friendly (Allen et al., 2003).
Chiang et al. (2011) argue that an organization might adopt HRM practices that signal POS for
employees. Liu (2004) finds a significant positive relationship between HRM practices (pay
level, career development opportunity, work-family support and relationship with leaders)
and POS. Karatepe and Vatankhah (2014) and Arefin et al. (2015a, b) find that when HPWPs
are appropriately implemented, they may create a positive impression of organizational
support among the employees. Based on the exchange relationship, HPWPs show how an
organization creates a work environment where employees feel that their performance and
contribution are cared for and valued, and thus, they perceive organizational support. As
such, HPWP is an effective strategy to make employees feel getting support from the
organization. Therefore, the following hypothesis can be considered in this context:
H3. Employee perceived HPWPs is positively related to POS.
3.3 POS and employee outcomes High-
Employee perceived support is considered as a mechanism for enhancing employee performance
attachment with and performance in the organization. In assessing employee performance,
POS is found to be a dominant factor. Shanock and Eisenberger (2006) find a significant
work practices
positive relationship between POS and employee in-role performance. In a meta-analytical
review, Riggle et al. (2009) assess the effect of POS on employee outcomes and find a
significant positive influence on employee job satisfaction, organizational commitment and
more on employee performance. Whenever organizations provide support to their employees,
they perceive their contribution as meaningful, and they contribute more to the organization’s
productivity (Rubel and Kee, 2013). Karlowicz and Ternus (2009) discover that proper
support from the management can enhance the quality of registered nurses’ services. Kumar
(2008) finds how POS significantly improves registered nurses’ expertise.
Furthermore, empirically POS is found to be negatively related to turnover intention
(Masterson et al., 2000). Sorgaard et al. (2007) find that lack of perceived support is the reason
for increased stress and burnout among a team of registered nurses and, consequently, for
their turnover. Stilwell (2001) suggests the potential for good leadership and management
support for health employees’ motivation and retention. Filipova (2011) finds the negative
impact of POS on nurse turnover intention and suggests that health management can
minimize turnover intention if nurses feel they are adequately cared for and valued. POS
might make employees feel emotionally attached to the organization; hence, they would be
less likely to intend to leave. Therefore, such prior research help to draw the following
hypotheses:
H4a. POS is positively related to in-role performance.
H4b. POS is negatively related to turnover intention.

3.4 POS as mediator

HRM scholars have considered HRM practices as organizational supports; however, they
have studied HRM practices and POS as two different constructs using different
measurement items (Allen et al., 2003). Moreover, POS is found as a significant mediating
contributor in previous HRM literature as well (Dawley et al., 2010; Allen et al., 2003).
Masterson et al. (2000) find the partial mediating effect of POS on procedural, distributive
justice and employee turnover intention. Filipova (2011) shows a mediating effect of POS
between ethical climate and job satisfaction, organizational commitment and turnover
intention of nurses in the Midwestern United States. Vatankhah et al. (2017), Arefin et al.
(2015a, b) and Karatepe and Vatankhah (2014) substantiate the significant mediating effect of
POS between HPWPs and different employee outcomes in the workplaces.
Previous research on health employees consider different variables, for instance,
psychological empowerment (Bonias et al., 2010), job satisfaction and employee
commitment (Baluch et al., 2013) and employee engagement (Ang et al., 2013) as mediators
between HPWPs and employee outcomes. The existing literature indicates a lack of research
on POS as a mediator in the said relationship. This study applies POS as a mediator to
address such a gap. Therefore, we assume the following hypotheses:
H5a. POS will mediate the relationship between HPWPs and in-role performance.
H5b. POS will mediate the relationship between HPWPs and turnover intention.
JAMR 4. Methodology
4.1 Sample
The current cross-sectional study collects data in 2019 (April 2019–June 2019) from different
categories of medical practitioners (doctors) working in different private hospitals in
Bangladesh. Researchers communicate to the top 50 hospitals, and only 30 hospitals
participated. Based on such reply, questionnaires were circulated to the HR managers of the
respective hospitals using the drop-off/pick-up method as it permits the respondents to fill up
the questionnaire alone at their convenient time (Maclennan et al., 2011). This study employed
purposive judgmental sampling. The sample includes medical doctors who held full-time jobs
as medical officers, surgeons and specialists and have at least two years of experience in the
hospital. We believe that the duration of employment is an essential factor for obtaining a
more accurate and fair evaluation of perceived organizational practices from the respondents.
This criterion serves to ensure that respondents are familiar with HPWPs.
Of 750 questionnaires distributed, 255 questionnaires were returned. 37 questionnaires
were excluded due to incomplete information. In total, 218 questionnaires were deemed
completed for data analysis, which represents a response rate of 29.06%. According to Hair
et al. (2014), there is no specific requirement related to sample size when using PLS-SEM.
Moreover, these authors also claim that 100 cases are sufficient to achieve acceptable levels of
statistical power in PLS-SEM. In Bangladesh, Rubel and Kee (2013) find significant results
from 149 cases of nurses.

4.2 Measures
All the employee perceived variables are measured by taking measurement items from prior
studies and using a five-point Likert Scale ranging 1 (strongly disagree) to 5 (strongly agree).
We adopted three items from Jawahar and Hemmasi (2006) to measure turnover intention.
Three items from Rubel and Kee (2013) were employed to assess employee self-reported in-
role performance (α 5 0.901). Earlier research recommends a self-performance rating as it has
been found to both correlate with and superior to the supervisor’s rating of performance
(Hooft et al., 2006). HPWPs incorporates five HRM dimensions. A three-item scale assesses
performance appraisal, training and development, and career development opportunity for
each, were adapted from Baluch et al. (2013) and Liu (2004). Both participation and
compensation were measured using a three-item scale, respectively, based on the research
work of Chen and Huang (2009). The alpha values of all the items of these five constructs
ranged from 0.76 to 0.92. Lastly, POS was measured with five items adapted from
Eisenberger et al. (2001) (α 5 0.84).

4.3 Statistical analysis

Partial Least Square Path Modelling (PLS-PM) is used to assess both measurement and
structural models. In this case, we apply PLS path modeling with a path-weighted scheme for
the inside approximation and then, using nonparametric bootstrapping with 1000
replications to obtain the standard of the estimates (Wetzels et al., 2009). The repeated
indicator approach is used for the hierarchical reflective construct (HPWPs). To evaluate the
hierarchical model of HPWPs, PLS also considers estimating the parameters of the inner and
outer models. Additionally, survey data are input into the Statistical Package for Social
Science (SPSS) v. 20 to conduct the descriptive statistical analysis.

4.4 Common method variance

Due to the self-report measures run the risk of common method bias, the possibility for
common method variance (CMV) cannot be ignored. The present study follows the proximal
and methodological separation method to solve the CMV issue suggested by Podsakoff et al. High-
(2003). In the questionnaire, separate sections with instructions are assigned to present the performance
measurements of each construct. Again, to minimize the CMV, we reduce evaluation
apprehension and social desirability effects by stating in the questionnaire that there are no
work practices
right or wrong answers and that respondents should answer questions as honestly as
possible. The items of the test are reviewed by experts, thus ensuring the clarity of wording
and content validity. Finally, we employ a statistical technique, the Harman single-factor
assessment, to establish the magnitude of CMV. The un-rotated factor analysis produces the
first factor explaining only 39.06% of the total 71.65% variance and thus, prove that CMV is
not a concerning issue.

Demographic information Respondents (N 5 218) Percentage (%)

Gender
Male 148 67.8
Female 70 32.2
Age
25–34 years 109 50.0
35–44 years 78 35.8
45 and above 31 14.2
Religion
Muslim 178 81.6
Non- Muslim 40 18.4
Marital status
Single 65 29.8
Married 153 70.2
Income
Below Taka 50, 000 47 21.6
Taka 50, 000 to 100, 000 70 32.1
Take 100, 000 and above 101 46.3
Position
Medical Officer 154 70.6
Surgeon 34 15.6
Specialist 30 13.8
Work experience
1–4 years 70 33.1
5–9 years 66 30.3
10–14 years 49 22.5
14 years above 33 15.1
Educational qualification
Bachelor of Medicine (MBBS) 89 40.8
Doctor of Medicine (MD) 46 21.2
Diploma in Medicine 43 19.7 Table 3.
Diploma in Surgery 29 13.3 Demographic profile of
Fellow of College of Physicians and Surgeons 11 5.0 the respondents
JAMR 5. Results
Table 3 presents the results of the demographic information of the surveyed respondents. In
this study, the average age of the respondents is 34 years. Half of the respondents are 25–34
years old (50.0%). About two-thirds of them are male (67.80%). Their average work
experience is about eight years.

5.1 Hierarchical HPWPs model

We employ the method of repeated indicators to assess the higher-order latent constructs in
which a higher-order construct is directly assessed by observing the indicators of all the
first-order constructs (Chin, 2010). The current research calculates whether the hierarchical
construct (HPWPs) is adequately presented as a reflective construct by investigating the
correlations among all the indicators of the five constructs in the first order, as suggested by
Hulland (1999). The results show that all first-order items are correlated and statistically
significant at p < 0.01 (Table 4). The path coefficients from HPWPs to its components in the
first order are significant at p < 0.001. The composite reliability (CR) and average variance
extracted (AVE) of HPWPs are 0.893 and 0.628, respectively. Table 4 represents the results of
the AVE and CR value of the hierarchical HPWPs and the related outcomes of its first-order
dimensions.

5.2 Measurement model

To assess the measurement model, we conduct a confirmatory factor analysis (CFA) to ensure
reliability, convergent validity and discriminant validity. As shown in Table 5, all item
loadings are above 0.5; all AVEs and CR results are well above the cut-off values of 0.5 and
0.7, respectively, as recommended by Hair et al. (2014). In this study, the lowest CR is 0.814,
and AVE is 0.602, as reported for CDO. Therefore, the research can ensure convergent
validity because it fulfills the criteria for acceptability.
Again, discriminant validity shows the extent to which one construct is different from the
other in the model by an empirical standard (Hair et al., 2014). In this research both Fornell-
Larcker method (Fornell and Bookstein, 1982) and heterotrait-monotrait (HTMT) (Henseler
et al., 2015) were employed to see the discriminant validity. In Fornell-Larker criteria, the
square root of AVEs (i.e. values of all the diagonal numbers) is found to be much greater than
the correlations of the constructs of corresponding off-diagonal ones (Chin, 2010).
Furthermore, for HTMT the value should be ≥ 0.85, (the stricter criterion) or ≥ 0.90 (the
model lenient criterion) suggested by (Henseler et al., 2015). Results of the analysis exhibit
that the HTMT values are found within the limit of the stricter criterion of ≥ 0.85. Thus, the
measurement model fulfils the discriminant validity criteria (see Tables 6 and 7).

5.3 Structural model

To examine the hypothetical relationships among the variables, a structural model is
developed. As shown in Table 8 and Figure 2, the paths from HPWPs to both endogenous

(CR 5 0.893, AVE 5 0.628)

Career development Performance Training and
opportunity Compensation Participation appraisal development

R2 5 0.425 R2 5 0.689 R2 5 0.560 R2 5 0.725 R2 5 0.741

Table 4. β 5 0.652 β 5 0.830 β 5 0.748 β 5 0.852 β 5 0.861
Hierarchical HPWPs p < 0.01 p < 0.01 p < 0.01 p < 0.01 p < 0.01
Items Loading AVE CR
High-
performance
Training and Development 0.677 0.863 work practices
The organization provides a supportive learning environment via training and 0.861
development program
I have opportunities to use the knowledge and skills I have learned from training 0.797
and development program
Opportunities to learn (training) are made available in the organization 0.809
Performance Appraisal
My performance goals are clearly defined in the appraisal process 0.770 0.716 0.883
Performance appraisal in the organization is fair 0.884
I receive feedback from my supervisor on my performance 0.879
Career Development Opportunity 0.602 0.814
The organization is supportive of my long-term career development 0.847
The organization provides an environment where I will accomplish my career 0.875
goals
The organization provides me an opportunity to grow and to exploit my potential 0.570
to excel and achieve my career goals
Compensation
I am compensated based on my performance and abilities 0.917 0.823 0.933
I am familiar with the criteria used to determine my compensation 0.883
My pay is fair relative to the pay received by others who hold similar position in 0.922
other organizations
Participation
I am often asked by my supervisor to participate in decisions 0.906 0.706 0.877
I have the opportunity to suggest improvements in the way things are done in the 0.910
organization
I am given autonomy while doing my job 0.686
Perceived Organizational Support
I feel my organization shows great concern for me 0.870 0.734 0.932
I feel my organization really cares about my well-being 0.901
I feel help is available when I have a problem 0.866
I feel my organization takes pride in my success at work 0.901
I think my organization extends help to perform my job in a best way 0.736
Employee Performance
I meet formal performance requirements of my job 0.777 0.775 0.911
I perform all those tasks that are required of me 0.930
I adequately complete assigned tasks 0.926
Turnover Intention
I will leave the organization as early as possible 0.937 0.871 0.953 Table 5.
I am actively searching for an alternative to the organization 0.937 Result of the
I often look for another job 0.926 measurement model

variables (employee in-role performance and turnover intention) indicate significant

relationships between them, with values of (β 5 0.568, p < 0.01) and (β 5 0.579,
p < 0.01), respectively. Furthermore, the path from HPWPs to POS is also found to be positive
and statistically significant (β 5 0.691, p < 0.01), while the other paths from POS to employee
performance (β 5 0.263, p < 0.01) and POS to turnover intention (β 5 0.290, p < 0.01) also
show significant relationships. Table 8 exhibits the outcomes of the hypothesized
relationship.
JAMR CDO COM EP PA PART POS T&D TI

CDO 0.776
COM 0.464 0.907
EP 0.349 0.717 0.880
PA 0.470 0.578 0.613 0.846
PART 0.397 0.510 0.545 0.522 0.840
POS 0.406 0.522 0.655 0.567 0.697 0.857
T&D 0.446 0.630 0.663 0.677 0.521 0.528 0.823
TI 0.430 0.756 0.564 0.566 0.702 0.689 0.567 0.933
Table 6.
Discriminant validity Mean 4.15 4.16 3.90 4.05 3.81 3.80 3.96 3.10
of the constructs SD 0.588 0.683 0.707 0.610 0.679 0.693 0.621 0.952
(Fornell-Larcker Note(s): Diagonals (in italics) represent the square root of the average variance extracted (AVE) while the
method) other entries represent the correlations

CDO COM EP PA PART POS T&D TI

CDO
COM 0.111
EP 0.217 0.324
PA 0.077 0.508 0.182
PART 0.200 0.081 0.188 0.164
POS 0.131 0.667 0.500 0.45 0.077
T&D 0.150 0.132 0.407 0.075 0.559 0.075
Table 7. TI 0.318 0.084 0.183 0.074 0.279 0.081 0.129
Discriminant validity Note(s): COD 5 Career development opportunity, COM 5 Compensation, EP 5 Employee performance,
of the constructs PA 5 Performance Appraisal, PART 5 Participation, POS 5 Perceived organizational support,
(HTMT0.85) T&D 5 Training and development, TI 5 Turnover intention

Std. Std.
Path (direct path) beta Error t. Value Decision

High Performance Work Practices > Employee Performance 0.568 0.052 10.880** S
High Performance Work Practices > Turnover Intention 0.579 0.047 12.261** S
High Performance Work Practices > Perceived Organizational 0.691 0.044 15.590** S
Support
Perceived Organizational Support > Employee Performance 0.263 0.061 4.325** S
Perceived Organizational Support > Turnover Intention 0.290 0.049 5.857** S
**p < 0.01, *p < 0.05, (analyzed the direct relationship based on one-tailed)

Std. Std.
Path (Indirect Path) beta Error t. Value Decision

High Performance Work Practices > Perceived Organizational 0.182 0.044 4.09** S
Support > Employee Performance
High Performance Work Practices > Perceived Organizational 0.200 0.036 5.48** S
Support > Turnover Intention
Table 8.
Result of path analysis **p < 0.01, *p < 0.05, (analyzed based on two-tailed)
 High-
performance
work practices

Figure 2.
Structural model with
higher order HPWPs,
perceived
organizational support
and behavioral
outcomes

This study also assesses the mediating effect of POS on both HPWPs and employee
performance and HPWPs and turnover intention relations. In this regard, we employ
Preacher and Hayes (2008) recommendations and the result of the analysis show the
significant mediating effect of POS between HPWPs and employee in-role performance
(β 5 182, p < 0.01) and HPWPs and turnover intention (β 5 0.200, p < 0.01). Regarding
confidential interval, Preacher and Hayes (2008) recommend that if the upper and lower limit
values do not straddle zero, then this indicates mediation. Our research findings fulfil these
criteria and find a significant mediating effect of POS between HPWPs and employee in-role
performance (LL 5 0.095, UL 5 0.268), and HPWP and turnover intention (LL 5 0.271,
UL 5 0.130).

6. Discussion
This study intends to serve the purpose of exploring the relationship among employees’
perceptions of HPWPs, POS and their outcomes at the employee level. Here, HPWPs are
theorized as performance-focused HRM systems. As mentioned earlier, the investigation of
HRM system strength and employee responses to the overall HRM system used in shaping
positive employee outcomes symbolize essential requirements in the HRM literature (Kehoe
and Wright, 2013; Afsar et al., 2018). Thus, a fundamental contribution of the present study is
providing such evidence in this regard, specifically, in the domain of HPWPs system strength
and employee outcomes relationship. We develop and test a HPWPs-employee outcomes
(in-role performance and turnover intention) model in which POS mediates the relationship. In
doing so, the study empirically investigates a higher-order reflective HPWPs model that
conceptualizes HPWPs as a combination of five reflective HRM practices (participation,
training and development, performance appraisal, career development opportunities and
compensation) that are mutually reinforcing and reflect HPWPs as an overall system. We
predict HPWPs might influence POS, turnover intention and in-role performance of the
healthcare professionals of Bangladesh, where there have been no studies to examine such
relation.
Overall, our findings support our expectations. This study confirms the significant
positive relationship between HPWPs and in-role performance and simplifies how HPWPs
can be a good indicator of employee in-role performance. This result is also supported by
previous literature (Rubel et al., 2018). The effect of HPWPs on employee in-role performance
JAMR is significant. HPWPs help healthcare professionals to remain focused on their performance
that would eventually affect the healthcare services. HPWPs satisfy employee performance-
centered needs in a formal performance-oriented work context. Taking the empirical support
from previous literature together with our results, we can confirm that employee perceived
HPWPs, in particular, seems to be associated with enhanced employee performance for the
betterment of the organization.
Our study satisfies our expectation regarding the negative effect of HPWPs on turnover
intention. This indicates that health employees might have less possibility to leave the
organization if the organization practices HPWPs. Conversely, health employees would be
more committed and devoted to the organization and would think about how to nurture a
long-term relationship with the organization if HRM practices are perceived as performance
focused. Literature review (Harley et al., 2007; Baluch et al., 2013) has proved the negative
association between HPWPs and turnover intention that is further authenticated by the
present finding. As today’s employees seek the purposes of working for a particular
organization in a long-term relation, HPWPs signals the message that employees are the key
performers of the organization. In a performance-focused work context, employees remain
interested in working and utilizing their potency to serve the organization. Seeing the
connection between their performance and organizational success, they further plan for
improving their performance levels, which leads them toward long term connectivity with the
organization. They feel for the organization, develop a psychological attachment with it and
see their future career in the organization.
Moreover, this study finds that employee perceived HPWPs has a positive influence
on POS in health organizations. This finding corroborates previous findings asserting
that HRM practices and POS are positively and significantly related (Allen et al., 2003;
Liu, 2004). In the context of Bangladesh, health employees also expect HPWPs
to enhance their POS at the workplace. This study reveals that perceived HPWPs
further facilitate employee perceptions of organizational supports in taking care of and
respecting them as they are the superior contributors of the organization. HPWPs
lead to POS, making the employees feel more supported and esteemed in the
organization.
Additionally, the findings of this study uncover that POS significantly positively
relates to in-role performance and negatively relates to turnover intention. In assessing
the effect on performance, prior study reports a positive result of POS (Karlowicz and
Ternus, 2009; Kumar, 2008). Present research also shows similar findings. In the case of
health organizations, Alfes et al. (2013) also find the same adverse relationship between
POS and turnover intention of nurses. POS builds an innate strength in the organization
that refines employee outcomes in terms of improved task performance and lower
turnover intention. Employee reciprocates perceived support through exerting high
level of efforts in required tasks and remaining with such organization. POS develops a
reason for the employees to stay with the organization. Perceived support fosters the
enthusiasm of employees to perform better and continue employment relationship with
the organization.
This study further confirms the mediating role of POS in the relationship between HPWPs
and employee turnover intention and in-role performance. Employees’ perceived supports
from organizations, derived from their perceptions of HPWPs, strengthen their retention
intention and in-role performance, particularly in the healthcare organizations of a
developing country like Bangladesh. Therefore, when employees feel the organization is
practicing HPWPs, taking care of them and valuing their contribution, the result would be
less turnover intention and more focus on performance, as the norm of reciprocity assumes.
HPWPs provide opportunities to utilize as well as develop employee potentialities, bolster
their intrinsic motivation to perform and remain in the organization through perceived High-
support experiences. performance
As such, the findings from the present research suggest that HRM practices lead to
positive employee outcomes in healthcare settings in Bangladesh. For the advancement of the
work practices
employees as well as the organization, healthcare organizations should identify the
dimensions of performance focused HRM practices to stimulate employee attachment and
improved performance. Along with HPWPs dimensions, healthcare organizations also need
to provide adequate support for employees’ well-being and to enhance their positive attitudes
and motivation, value them to augment their commitment and sense of belongingness to the
organization. Healthcare organizations in a developing country like Bangladesh, should
design and implement employee centered HPWPs in their employee management strategies
to improve HR and organizational performance.

7. Managerial implications
Our study makes important contributions. Our findings highlight that organizations need to
ponder beyond the operative structure of an HRM system and to focus on HPWPs. We
include work outcomes of employee perceived HPWPs in a single hierarchical reflective
model. Our study contributes to the available HRM literature in two ways. On the one hand,
the relationship of the HRM-employee outcome is further authenticated from the perspectives
of HPWPs system and employee responses interactions. We demonstrate significant
relationships between health employees’ HPWPs perceptions, turnover intention and
performance. Our study extends the research understanding of the causal sequence by which
HPWPs are likely to have an impact. Our findings suggest that employees’ perceptions of
HPWPs influence employees’ behaviors at a level of their influence on POS. So far, little, if
any, research has both theoretically and practically examined what POS might do in creating
a work context crucial for expected employee behaviors to be a consistent result from the
perceived HPWPs. This study proves POS as an effective pathway of impacting HPWPs on
employee performance and retention.
We view HPWPs as a win-win approach in HRM system strength for both employees and
organizations. Implementing such practices as a blend of mutually reinforcing HRM
practices, especially considering that employees get motivation (well-compensated),
knowledge (training and development), feedback (performance appraisal), autonomy
(participation), guidance and direction (career development opportunity), might decrease
turnover intention and increase performances of the employees. Consequently, both
employees and organizations could enjoy the benefits of increased performance in a
continuing relationship as a critical success factor. Therefore, presenting such practices as
reflectors of HPWPs system strength is crucial for an organization.
Similarly, organizations having supports for employees in the forms of caring and valuing
them are more likely to be considered as better places to work. As employees are no longer be
viewed as machines; instead, they are perceived as total feeling beings with human values,
they have their self-respect senses, taking care of them and acknowledging their
contributions is a must. It is evident that when the organization is supporting employees,
they are ready to reciprocate by being better performers with a higher level of retention. They
remain confined with their organizations and work for accomplishing organizational goals.
Every individual is a unique person and holds some potentialities at the workplace.
Organizations need to discover, grow and foster that hidden expertise of employees to get
their best performance. In this competitive business war for survival, human dependency is a
key. Organizations need to depend on their human factors to achieve sustained consistent
performance. It is particularly true for service organizations where the human touch is
considered vital for customer satisfaction. Service organizations must have a collaborative
JAMR mechanism of HPWPs and POS so that a culture of employee retention and productivity can
be nurtured. Importantly, hospital management must understand that the implementation of
HPWPs might be insufficient to elicit desired employee behavioral outcomes. The main
mechanism by which HPWPs system contributes to desired employee outcomes is by
supporting their employees (POS).
To sum up, encouraging the performance-oriented system of a blend of reinforcing HRM
practices, mainly considering that employees have the autonomy to flow ideas (participation)
freely, get inspiration (adequately compensated), can utilize and develop talents (training and
development), obtain feedback (performance appraisal), and see career progression ladders
(career development opportunity), HPWPs might reduce turnover intention and enhance
performance of the employees. Such a work setting would promote the workforce to remain
and consistently create performance value for the organization. Moreover, together with POS,
HPWPs in the hospital not only develops top performers but also helps in maintaining their
continuity in the organization. Such practice of efficient deployment of HPWPs with the
support of POS helps in winning the best possibilities from employees, flourishing the service
operations, and satisfying and retaining them amidst employee turbulence tendency. Thus,
HPWPs requires an organization to invest in employees and to utilize them as valuable
assets, helping to overcome the employees’ intention to leave and thus, leading to an overall
consistent organizational performance.

8. Limitations and future research direction

Several limitations encumber this study. First, this study considers only medical doctors.
Therefore, future research should extend research and include both medical and non-medical
employees for a more scientific comparison in the same industry. Second, this study only
covers private hospitals operating in Bangladesh. Therefore, the results cannot be
generalized for all health employees worldwide. Thus, future researchers should consider
other locations, as well as both private and public hospitals as their study sample. This would
give a clearer picture of the similarities and differences regarding the HPWPs of private and
public health organizations in a similar and different country context.
Furthermore, this study recommends including more respondents to achieve higher
reliability and validity of the model. Another limitation of this study is measuring employee
performance by self-measuring procedures, by which biases may occur. Future researchers
can consider both supervisor and employee rating to measure employee performance. Last,
suggestions for future research include an attempt to conduct a study over 3 time points
within the workplace. There is a need for an extended 3 wave study in order to accurately
examine the longitudinal effects of the model.

9. Conclusion
We have attempted to offer a scholarly update on HRM system strength, in this case, is
HPWPs. We also shed some light on essential employee outcomes in general and in the
healthcare setting in particular. We conclude that the HRM system strength in the form of
HPWPs construct is highly related to employee outcomes such as POS, turnover intention
and in-role performance. Our findings strengthen the idea that when HPWPs system strength
finds its way into actual practice in the organization, the management in the healthcare
industry can expect better performance and retention of their talents through POS. More
specifically, the health industry should pay significant attention to the utilization of HPWPs
for managing their employees as their performance and retention indicate sustainable patient
satisfaction and better health services for society. To ensure that these outcomes are
achieved, care must be taken when designing and delivering HPWPs.
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Corresponding author
Mohammad Rabiul Basher Rubel can be contacted at: asstprof_sub@yahoo.com

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