High-Performance Work Systems in the Healthcare Industry: A Systematic Literature Review

Abstract

This research study aims to unveil the key features of contemporary literature on high-performance work systems (HPWS) in the domain of healthcare by carrying out a systematic literature review of relevant scientific studies from existing literature published in top-rated journals (Australian Business Deans Council (ABDC) listed). The article aims to develop a comprehensive understanding of theoretical foundations, concepts, level of the study, variables and recent trends in the area. The Scopus database is used to identify the scientific publications for this study. Based on the search query and inclusion & exclusion criteria, the short-listing process resulted in 72 articles published between 2006 and 2021. From the short-listed articles, the authors have identified 45 relevant studies connected to the HPWS area in the healthcare domain that was published in top-rated journals listed in ABDC. The authors have systematically analysed the selected studies. A critical review of the existing literature helped gather and present details relating to the theoretical framework referred to, intervening variables, performance outcomes, methodological concerns, etc., Also, research gaps have been identified and the avenues for future research are suggested. In addition to this, the authors have conducted a bibliometric analysis to check for the domain knowledge structure, trending topics and themes of HPWS research in the healthcare industry.

Keywords

High-performance work systems HPWS healthcare hospitals HRM practices systematic literature

Introduction

Healthcare is a labour-intensive industry that requires effective Human Resource Management (HRM) practices (Bartram & Casimir, 2007; Stanton, 2008). Hospitals emphasize the adoption of suitable HR practices and policies for increasing their effectiveness like all other organizations (West et al., 2006). Researchers in the HRM field have been trying, for the past three decades, to identify appropriate HRM practices that make a system and contribute to higher organizational performance (Messersmith & Guthrie, 2010). The system of HRM practices termed as ‘high-performance work system or HPWS’ is defined by Datta et al. (2005) as ‘a set of HR practices designed to enhance the employees’ skills, commitment and productivity in such a way that employees become a source of competitive advantage’.

The initial studies exploring the HPWS–performance link, till recently, have been limited mostly to the manufacturing sector (Zacharatos et al., 2005). They were later expanded to the service sector when researchers realized that something similar could be applied to other industries as well (Katou et al., 2014). It is argued that the findings of the studies conducted in the manufacturing sector could not be matched or applied to the service sector (Kloutsiniotis & Mihail, 2020).

HPWS research has gained significant importance in service industries as it has spread to a variety of service industries like tourism and hospitality/hotels (e.g., Chand, 2010; Chen et al., 2017; Karadas & Karatepe, 2019; Karatepe, 2013; Kloutsiniotis & Mihail, 2017; Sun et al., 2007; Takeuchi et al., 2018; etc.), banking (e.g., Chang, 2015; Cooke et al., 2019; Kloutsiniotis & Mihail, 2018; Muduli et al., 2016; Rubel et al., 2018; Siddique et al., 2019, etc.), Healthcare (e.g., Bartram et al., 2014; Gittell et al., 2010; Leggat et al., 2010; Liu et al., 2020; Young et al., 2010; etc.), Airlines (e.g., Karatepe & Vatankhah, 2014; Alafeshat & Tanova, 2019, etc.), professional service firms (e.g., Fu, 2013; Fu et al., 2013, 2015, 2016, 2017, 2019) and many others.

In this study, the main focus is on providing a comprehensive overview of the scientific studies on HPWS that are exclusively conducted in the healthcare industry across the world. After a critical examination of the previous HPWS literature pertaining to the healthcare industry, the authors have identified a literature review study conducted by Etchegaray et al. (2011). Mainly, the study by Etchegaray et al. (2011) concentrated on identifying how HPWS was measured in healthcare settings by the previous researchers. In the present study, the authors aimed to develop a more systematic and exhaustive understanding of the research area relating to the clarity of the term HPWS, the level of the studies conducted, the theoretical framework referred, intervening variables, performance outcomes, the methodological concerns, etc., through a critical examination of the up-to-date literature of HPWS healthcare studies and also shed light on current trends. The studies highlight prospective areas for future research.

Research Methodology

To identify the scientific publications for this study, the Scopus database, a comprehensive database consisting of 20,000+ peer-reviewed journals in the fields of social sciences, arts & humanities, science and technology (Fahimnia et al., 2015) was used. The initial search was conducted with the following search query designed by the authors:

(‘High Performance Work System’ OR ‘High-performance work systems’ OR ‘HPWS’ OR ‘HR Systems’ OR ‘HRM Systems’ OR ‘HR Bundles’ OR ‘High Performance HRM Practices’ OR ‘High Performance Work Practices’ OR ‘HPWP’ OR ‘High commitment HRM’ OR ‘High Involvement HRM’) AND (‘Healthcare’ OR ‘Health care’ OR ‘Hospitals’ OR ‘Clinicians’ OR ‘doctors’ OR ‘nurses’ OR ‘medical’ OR ‘medicine’ OR ‘ICU’).

The authors have prepared the inclusion and exclusion criteria to short-list the articles. The inclusion and exclusion criteria are as follows:

Inclusion criteria:

The article must be highly relevant to the HPWS field.

The studies must have been conducted in the healthcare industry only.

The studies can be research papers (both empirical and theoretical), conference proceedings, book chapters, editorials and viewpoints/notes.

Both published articles and the articles in the press.

Articles should be in English.

Exclusion criteria:

Studies that are NOT relevant to the HPWS field.

Studies that are NOT conducted in the healthcare industry.

Dissertations, published books and erratum.

‘From’ and ‘to’ dates were not set during the search in the database and the initial search resulted in 147 articles published between 1957 and 2021. Then, based on the shortlisting criteria mentioned above, the primary short-listing process resulted in 72 articles published between 2006 and 2021. In the next step, from the short-listed 72 articles, authors have identified those articles that were published in top-rated journals listed in the Australian Business Deans Council (ABDC) by manually checking each journal’s name in the official ABDC list of journals published up to the year 2019 (list is available at: https://abdc.edu.au/research/abdc-journal-quality-list/). This resulted in the identification of 21 journals in which 45 articles were published.

A clear picture of the research methodology adopted for the article short-listing process for this study is depicted in the PRISMA flow diagram in Figure 1.

Figure 1.

PRISMA Flow Diagram.

Upon examination of each of these 45 papers to confirm high relevancy, the authors scanned each article and these 45 articles, which included theoretical and empirical articles, were finally included in this study. The journals considered for this study are mentioned here along with their ABDC categories (i.e., A* or A or B or C).

International Journal of Human Resource Management (A); Health Care Management Review (A); Personnel Review (A); Journal of Health, Organization, and Management (B); Human Resource Management Journal (A); Asian Academy of Management Journal (C); British Journal of Industrial Relations (A*); Business Process Management Journal (B); Employee Relations (B); European Management Journal (B); Health Services Research (A); Human Resource Management (A*); IEEE Transactions on Engineering Management (A); International Journal of Manpower (A); International Journal of Quality and Service Sciences (B); Journal of Applied Behavioural Science (B); Journal of Applied Psychology (A*); Journal of Occupational Health Psychology (A); Journal of Organizational Behaviour (A*); Journal of Service Management (A); Organization Science (A*).

In addition to the systematic review of the HPWS healthcare literature, a bibliometric analysis of all the included articles has been conducted by the authors to explore the HPWS research domain knowledge structure in the healthcare industry, the trending topics in the HPWS healthcare research over a period of time, and also to identify the key themes that emerge in the HPWS healthcare research. Authors have applied bibliometric techniques like keyword analysis and thematic analysis to generate the results.

Results and Discussion

Table 1 presents the details of the number of articles published in each shortlisted journal for this study.

The analysis of the results revealed that, among the 45 articles included in this study, 40 are empirical studies that are either quantitative or qualitative in nature, while 5 are theoretical- or conceptual-based articles that emphasize certain inputs from the findings of the existing literature to generate new insights. It is observed that the International Journal of Human Resource Management (IJHRM) has the maximum number with 12 publications among the 45 articles studied. Twelve articles were published in journals dedicated to publishing healthcare related research as first priority, such as Healthcare Management Review, Journal of Health Organization and Management and Health Services Research. Table 2 presents elaborate details of each empirical paper with its objectives, mediator or moderating variables used in the study, the dependent variable and the findings. The five theoretical- or conceptual-based studies are presented in Table 3.

Table 1.

List of Journals with the Number of Articles Published.

S. No	Journal	No. of Articles
1	International Journal of Human Resource Management	12
2	Health Care Management Review	8
3	Personnel Review	4
4	Journal of Health Organization and Management	3
5	Human Resource Management Journal	2
6	Asian Academy of Management Journal	1
7	British Journal of Industrial Relations	1
8	Business Process Management Journal	1
9	Employee Relations	1
10	European Management Journal	1
11	Health Services Research	1
12	Human Resource Management	1
13	IEEE Transactions on Engineering Management	1
14	International Journal of Manpower	1
15	International Journal of Quality and Service Sciences	1
16	Journal of Applied Behavioural Science	1
17	Journal of Applied Psychology	1
18	Journal of Occupational Health Psychology	1
19	Journal of Organizational Behaviour	1
20	Journal of Service Management	1
21	Organization Science	1

Table 2.

Research Goals and Findings of the Reviewed Empirical Articles.

S. No.	Study Details	Research Objective(s)	Mediator(s) / Moderator(s)	Dependent Variable(s)	Findings
1.	West et al. (2006)	Investigate the relationship between the HRM system and standardized patient mortality rates.	–	Patient mortality rate	Implementation of the high- performance HRM practices will impact patient mortality rates.
2.	Harley et al. (2007)	Investigate whether HPWS practices have a positive or negative impact on employee work experiences and to identify whether highly skilled or poorly skilled employees get more benefit out of HPWS practices.	–	• Job control • Organizational commitment • Job satisfaction • Intention to leave • Psychological Strain • Work efforts	Employees can benefit from HPWS in the service sector. Highly skilled nurses are no more likely than lowly skilled personal care workers in the healthcare industry to be subject to HPWS. Also, low-skilled workers have more positive outcomes than high skilled workers due to HPWS in some cases.
3.	Gittell (2008)	Explores the role of relationships in enabling resilient responses to external pressures and firm practices.	Perceived work stressors	Relational coordination	Presence of a particular type of HPWS increases the relational co-ordination among the employees and strengthens their resilient responses.
4.	Stanton et al. (2010)	Explores how the HRM is understood, interpreted and operationalized across the management hierarchy.	–	–	The key in creating a strong HRM system in the organization is to make all the managers in the hierarchy ‘sing the same song’.
5.	Gittell et al. (2010)	Explores how HPWS impact the relational coordination among the employees and consequently on the quality and efficiency outcomes of hospitals.	Relational coordination	Perceived quality of patient care and length of patient stay.	HPWS positively predicts the strength of relational coordination among various hierarchical employees and relational coordination mediates the HPWS and hospital outcomes.
6.	Boselie (2010)	Examines the effect of HPWPs on employee commitment and citizenship behaviour.	–	Affective commitment and OCB	Employee development and employee involvement practices create a high-performance work climate which leverages employee commitment and citizenship behaviour.
7.	Young et al. (2010)	Explore the attitude of managers and employees towards HPWS in a rural hospital.	Social identification	Affective commitment and job satisfaction	High performance work practices facilitate social identification through which employee attitude gets impacted
8.	Leggat et al. (2010)	Investigate the interactive effects of psychological empowerment and job satisfaction between HPWS and nurses’ perceptions of the quality of patient care.	Psychological empowerment and job satisfaction	Quality of patient care	Psychological empowerment fully mediated while job satisfaction fully moderated the HPWS–quality of patient care relationship.
9.	Veld et al. (2010)	Investigate employee perceptions of strategic goals and HRM at the ward level and their effect on outcome variables.	Climate for quality and climate for safety	Ward commitment	Employee perceptions on the HR system have significant influence on the climate for quality and safety and consequently on commitment.
10.	McAlearney et al. (2011)	Investigate the contribution of HPWPs in healthcare to improve the quality of patient care and patient safety.	–	Performance outcomes	Implementation of HPWPs in healthcare organizations supports the strategic goals in improving the quality of care and patient safety.
11.	Song et al. (2012)	Understand the organization’s perspectives, reasons and evaluation approaches on investments for HPWPs.	–	–	Studied organizations do not have explicit financial return expectations on HPWP investment. Rather, HPWP is treated as a means for competitive advantage and factors for execution of successful strategic priorities.
12.	Townsend et al (2012)	Investigate the extent of skilled clinicians’ preparedness in performing the role of the ward manager in a hospital which is aiming to adopt HPWS.	–	Preparedness for administrator role	It is found that nurses find themselves in line manager roles accidentally and are completely unprepared for what is required from them. The hospital has failed to harness the benefits of ward managers as an important role in the HR system. It is opined that the organizations are failing to fully develop employee skills that are required for managers before they promote them to the role of managers.
13.	Chuang et al. (2012)	Identify HPWPs associated with healthcare FLWs job satisfaction and perceived quality of care.	Job satisfaction	Perceived quality of patient care	Among the HPWPs, supervisor support and team-based work practices, when used in tandem with other practices, enhances job satisfaction and high quality of care.
14.	Leggat and Balding (2013)	Gather and examine the opinions on educational initiatives being planned for the improvement of leadership in quality and safety among medical, nursing, and allied health professionals.	–	Clinical leadership factors	Factors like emotional intelligence, resilience, self-awareness and understanding of other clinical disciplines are identified important for leaders. Capability frameworks and educational programmes for clinical leadership are necessary and need a broad focus.
15.	Ang et al. (2013)	Examine the role of management and employee perceptions of HRM practices on HR outcomes.	Job satisfaction, work engagement	Affective commitment, intention to leave	When management perceptions on the implementation of HR practices and employee perceptions on actual practices are in sync, HPWS leads to greater employee outcomes.
16.	Zhang et al. (2013)	Investigate the effect of HPWS on emotional exhaustion, work engagement through economic and social exchange perceptions and finally on job satisfaction.	Emotional exhaustion, work engagement, nature of employee–employer relationship	Job satisfaction	HPWS may lead to employee work engagement or cause emotional exhaustion depending on employee perception of the nature of the employee–employer relationship. Economic exchange perceptions lead to emotional exhaustion whereas social exchange perception leads to work engagement.
17.	Baluch et al. (2013)	Examine the impact of employee HR systems perceptions on patient satisfaction through employee civility towards patients.	Employee job efficacy, intention to leave, employee civility towards patients	Patient satisfaction	Employee perceptions on HR systems influence their civility towards the patients which has a consequent effect on patient satisfaction. Also, positive and negative mediation effects are observed for job efficacy and intention to leave, respectively, in HR system perceptions and employee civility link.
18.	Peining et al. (2013)	Investigate how perceptions on HR systems contribute to employee job satisfaction and organizational performance outcomes.	Job satisfaction	Customer satisfaction and financial performance	Employee perceptions on implemented HRM practices impact customer satisfaction through the mediating effects of job satisfaction.
19.	Bartram et al. (2014)	Examine the effects of HPWS on social identification and psychological empowerment and the consequent effect on the quality of patient care.	Social identification, psychological empowerment	Quality of patient care	There is a strong effect of HPWS on social identification which also mediates the HPWS– psychological empowerment relationship and the latter has shown a strong effect on the perceived quality of patient care.
20.	Dill et al. (2014)	Examine how career development focused HPWPs relates to individuals’ perceived mobility with their current employer and the consequent effects on job satisfaction and retention.	Perceived mobility	Job satisfaction and employee retention	Elements like tuition remission and educational release time positively predicted individual perceived mobility which then significantly predicts employee job satisfaction and intent to stay.
21.	Fan et al. (2014)	Examine the impact of HPWS in employee subjective well-being and workplace burnout.	Organizational based self-esteem (OBSE)	Subjective well-being, workplace burnout	HPWS increases employee subjective well-being and decreases workplace burnout. Well-being enhancing and burnout relieving effects are high when the employee has high OBSE.
22.	McAlearney et al. (2016)	Examine the role of HPWPs in CLABSI reduction and prevention in the hospitals under study by comparing high performing and low performing sites.	–	CLABSIs reduction and prevention efforts	At the high performing hospitals, certain HPWPs facilitated the reduction of CLABSI which was not the case in low performing sites.
23.	Mihail and Kloutsiniotis (2016)	Examine the effects of HPWS on psychological empowerment and consequently on the quality of patient care.	Social identification, psychological empowerment	Quality of patient care	HPWS affects employee psychological empowerment through their social identification while psychological empowerment impacts the quality of patient care being provided.
24.	Kellner et al. (2016)	Find evidence that HRM-oriented learning and development programmes for FLMs can impact their performance.	Learning and development programmes	Performance	All FLMs, when provided with certain ability, motivation and opportunity-enhancing policies, will perform well at work.
25.	Mihail and Kloutsiniotis (2016)	Examine the effects of HPWS on employee emotional exhaustion, work engagement and consequently on job satisfaction.	Emotional exhaustion, work engagement	Job satisfaction	The effects of HPWS on employee outcomes can be influenced by the exchange relationships that exist between the employer and employees.
26.	Kellner et al. (2016)	Develop an understanding of the HRM process, HRM philosophy and to study the interrelationships between these concepts and other HRM-performance related elements.	–	HRM messages and philosophy	HRM messages should come from the top management rather than the HR department and employees should have information on continuous improvement, best practices and innovation.
27.	Ogbonnaya et al., (2017)	Examine and compare the positive relationships between HPWP (as both integrated and independent) and employee health and well-being.	Work intensification	Health and well-being	HPWPs have shown positive effects in both the combined cases and work intensification mediated the relationships under study.
28.	Kloutsiniotis and Mihail (2017)	Examine the effect of HPWS on employee affective commitment and intention to leave with work engagement and job satisfaction as mediators.	Work engagement and job satisfaction	Affective commitment and intention to leave	HPWS had a positive effect on work engagement, job satisfaction, affective commitment and a negative effect on the intention to leave.
29.	Malik et al. (2017)	Examine the role of HRM in facilitating contextual ambidexterity and innovation in the healthcare industry.	–	Innovation	The use of high-involvement HRM practices helps in exploring new ideas and facilitates contextual ambidexterity in organizations which leads to innovation.
30.	Kellner et al. (2017)	Investigate whether the HPWS approach and the contradicting value-based system approach co-exist and result in a strong HRM system and climate in a non-profit organization.	–	Strong HRM system and climate	A modified HPWS influenced by values orientation softened the potentially conflicting elements of strategic HRM and complemented the firm values. A stronger climate, positive employee outcomes, and a high-performing HRM system is observed when a careful alignment of organizational values with HPWS is done.
31.	Schopman et al. (2017)	Investigate the mediating role of transformational leadership and intrinsic motivation between employee perceptions on HRM and motivation to continue at work.	Transformational leadership, intrinsic motivation	Workers’ motivation to continue to work	Transformational leadership and intrinsic motivation well mediated the link between HRM and workers’ motivation to continue to work.
32.	Nasurdin et al. (2018)	Examine the mediating role of nurses’ organizational commitment in HPWPs – turnover intentions relationship.	Organizational commitment	Turnover intentions	HPWPs led to reduced turnover intentions through organizational commitment.
33.	Gkorezis et al. (2018)	Examine the relationship between high performance work practices and nurses’ intention to leave with mediating and moderating mechanisms.	Organizational cynicism, HRM related educational background	Intention to leave	Intention to leave mediated and HRM related education plays a crucial role in the HPWP – intention to leave.
34.	Nasurdin et al. (2020)	Examine the mediating role of nurses’ job satisfaction in the HPWPs – job performance relationship.	Job satisfaction	Task performance and contextual performance	Nurses’ job satisfaction well mediated the relationship between HPWPs and job performance measures.
35.	Robbins and McAlearney (2020)	Investigate whether the implementation of HPWPs facilitates employee ability to speak up.	Manager behaviour and organizational structures	Employee ability to speak up	The implementation of certain HPWPs facilitates or removes barriers for the employees to speak up in organizations which is a focus for quality improvement and patient safety.
36.	Melián-Alzola et al. (2020)	Analyse the role of leaders and HPWPs in promoting organizational agility and its impact on employee satisfaction in ICUs.	Organizational agility	Employee satisfaction	The role of human dimension is important in promoting hospital agility and employee satisfaction.
37.	Wang et al. (2021)	Investigate whether and how employee personal and job resources help from refraining health impairment due to the service oriented HPWS.	Core-self evaluations, servant leadership, strain	Physical and mental health	For those employees having less core-self evaluations or leaders with lower servant leadership, the SHPWS increase their strain, which leads to the deprival of physical and mental health.
38.	Thirupathi et al. (2021)	Examine the moderating role of relational coordination in HPWS–overall performance (efficiency + effectiveness) relationship.	Relational coordination	Effectiveness,efficiency and overall performance	Relational coordination well moderated the HPWS–effectiveness link, while it has shown less significant results in the HPWS-efficiency link.
39.	Dahle and Urstad (2021)	Investigate how high-commitment HRM and Leader Member Exchange (LMX) facilitate the manifestations of the brand support.	Organizational commitment, LMX	Reputation strategy embeddedness, brand-congruent behaviour and brand development participation	Positive relationships were found between high-commitment HRM and LMX and brand support elements. Organizational commitment mediated all the links, and LMX moderated the HRM- reputation strategy embeddedness link.
40.	Al-Taweel (2021)	Studies the effects of adopting categories of HPWPs and their impact on specific performance elements (productivity, profitability, workers efficiency, innovation, etc.)	–	Performance-related elements	HPWPs led to the improvement of performance elements and also helped in achieving institutional goals and employee productivity.

Table 3.

Details of Theoretical / Conceptual Based Studies.

Study Details	Objectives	Findings
Etchegaray et al. (2011)	Examine the previous literature to understand how HPWS was measured by previous researchers in healthcare settings and understand the existing relationships between HPWS and outcomes.	There is no common agreement on which HR practices to include during the measurement of HPWS in the previous literature as the practices used by the researchers ranged between 3 and 10. The most common practices are teams/teamwork and training/development. HPWS has been linked to a variety of outcomes such as burnout, trust, service quality, customer satisfaction, job satisfaction, medication errors, patient costs, nurse perceptions of quality care, organizational performance or productivity and patient mortality. The HPWS–outcomes relationship in healthcare settings were positive with the majority studies showing favourable results. It is identified that none of the previous researchers created their HPWS measure in a systematic way that considered all possible HR practices.
Garman et al. (2011)	Develop a conceptual model of HPWS for the healthcare sector to determine how HPWP subsystems affect employee and organizational outcomes by reviewing the previous healthcare and other industry-based HPWS studies.	From the literature reviewed, certain organizational factors have been identified that influence HPWP adoption and certain factors that influence HPWP impact and sustainability. Four HPWP subsystems containing 14 HRM practices have been identified and categorized as practices under the following names: (a) Engaging staff–—communicating mission and vision, information sharing, employee involvement in decision-making, performance driven reward/recognition. (b) Aligning leaders–—leadership training linked to organizational goals, succession planning and performance-contingent rewards. (c) Acquiring and developing talent–—rigorous recruiting, selective hiring, career development and extensive training. (d) Empowering the frontline–—employment security, reduced status distinctions, teams/decentralized decision-making. All these subsystems will lead to certain organizational outcomes like higher quality, high safety and high efficiency. They will also lead to certain employee outcomes like high retention, high engagement, resilience, skills and general well-being.
Leggat et al. (2011)	Examine the literature on Australian HCOs to demonstrate a link between HPWS and performance outcomes, including the quality of patient care. To show that the studied Australian hospitals do not have the necessary elements of HPWS in place.	A positive relationship between HPWS and the quality of care is found which is mediated by certain HRM outcomes. Also, there is huge gap in strategic HRM aspects reported by CEOs and other managers thus indicating a policy and practice gap. It is also found that the studied Australian hospitals do not have the necessary elements of HPWS in place.
Cooke and Bartram (2015)	Examine the changing scenario in healthcare and aged-care or elderly care systems and identify the challenges for HRM. Also, access the existing literature on the role of HRM and HPWS in the healthcare sector.	It is found that the aged-care systems remain understudied or under researched. It is a fruitful area for future researchers. It is identified that the demand for residential elderly care and community-based health services is growing. But the well-being and retention of healthcare workers have become one of the key and crucial HRM challenges. Changes in social policies and public-sector management have had certain implications for HRM. Certain key elements such as actor, gender, time, place, space, ethnicity, hierarchy, power, class, interactions and intersections are deemed important in studying HRM in the healthcare sector to mobilize institutional support and effectively manage HRM practices at the firm level. It is suggested that HRM research in the healthcare sector be conducted by adopting an interdisciplinary, multi-level and multi-stakeholder approach. A clear multi-level and multi-stakeholder framework to manage the demand and supply of skill in elderly care has been outlined.
Vogus et al. (2020)	Develop a model of a compassionate system and detail its antecedents, its climate, behaviours and practices through which compassion can be achieved for delivery of high-quality healthcare and for the efficient reduction of suffering.	Compassionate leader behaviours and values combined with a compassionate HR system or HR bundles create a compassionate climate which consequently develops collective well-being (affective well-being and psychological well-being) when there is sufficient HR availability in the organization. All these lead to standardization and customization which ultimately result in efficiency and quality.

By observing the initial study results, it is clear that there is a gradual growth in HPWS healthcare studies and methodological issues such as single vs. multiple respondents and cross-sectional research design vs. longitudinal research design have also been addressed. Among the 40 studied empirical studies, the majority of the studies were based on the cross-sectional research design with only 2 studies having the longitudinal approach. All the studies that adopted the cross-sectional research design consider it a limitation and thus, there is a mention of adopting the longitudinal research in future endeavours as adopting the longitudinal research design helps gain a deeper understanding of research problems.

It is observed that the majority of the studies have used the term ‘HPWS’ to represent ‘HPWS’. But there are also studies that refer to terms such as HR systems, HRM systems, HPWPs, high-involvement HRM and high-commitment HRM. The study conducted by Etchegaray et al. (2011) underscored the disagreement among the HPWS researchers in identifying the HRM practices that make an HPWS. When reviewing the other recent general HPWS studies (Sun & Mamman, 2021), it is clear that this disagreement continued to exist among the HPWS research fraternity while identifying the appropriate list of HRM practices that make an HPWS. Most HPWS researchers have referred to HRM practices or HPWS scales from previous literature which is termed as benchmark studies (e.g., Sun et al., 2007; Zacharatos et al., 2005; etc.) which contain the complete list of HRM practices that make an HPWS (Kloutsiniotis & Mihail, 2020b). They have been studied in their respective research settings. The same was adopted by most of the healthcare HPWS researchers also.

For example, in a series of studies conducted by Bartram and his colleagues, Zacharatos et al. (2005) HPWS scale has been consistently adopted to represent HPWP and modified HPWS scales have been applied after verifying the relevancy and suitability of the HRM practices to the healthcare settings. Similarly, the studies conducted by Mihail and Kloustniotis (2016a, 2016b), Kloustniotis and Mihail (2017) in Greek healthcare organizations (HCOs) have taken a part of their HPWS scale from the scale developed by Delery and Doty (1996) along with Zacharatos et al. (2005). Likewise, Zhang et al. (2013), for their study in Chinese HCOs, referred to the work of Huselid (1995), Delery and Doty (1996) and Datta et al. (2005). The most frequent HRM practices in the majority of the healthcare studies are recruitment & selection/selective staffing, employment security, extensive training/training & development, self-managed teams & decentralized decision-making, reduced status distinctions, information sharing, transformational leadership, high-quality work and performance management.

The Theoretical Framework

Going further into the analysis, the most important observation is the theoretical framework that is used by researchers to connect HPWS practices with other variables in the process of exploring the HPWS–performance relationship. Researchers have referred to various HRM theories like the Organizational Behavioural Theory, the Labour Process Theory, the Contingency Theory, the Relational Coordination Theory, the Post Bureaucracy Theory, the Social Exchange Theory, the Social Identity Theory, the AMO Theory, the Resource-based View (RBV) Theory, the Psychological Contract Theory and the JD-R Theory. Among all the theories mentioned, the Social Exchange Theory is the most frequently referred to when analysing empirical studies.

In the process of unravelling the most underscored HRM black-box phenomena using the Social Exchange Theory, researchers tried to examine the impact of HPWS on different attitudinal and behavioural outcomes on employees like employee commitment (Ang et al., 2013; Boselie, 2010; Dahle & Urstad, 2021; Kloutsiniotis & Mihail, 2017; Nasurdin et al., 2018), OCB (Boselie, 2010), psychological empowerment (Leggat et al., 2010), job satisfaction (Ang et al., 2013; Kloutsiniotis & Mihail, 2017; Leggat et al., 2010; Mihail & Kloutsiniotis, 2016a; Nasurdin et al., 2020; Piening et al., 2013; Zhang et al., 2013), work engagement (Ang et al., 2013; Kloutsiniotis & Mihail, 2017; Mihail & Kloutsiniotis, 2016a;Zhang et al., 2013), intention to leave (Ang et al., 2013; Gkorezis et al., 2018; Kloutsiniotis & Mihail, 2017; Nasurdin et al., 2018), emotional exhaustion (Mihail & Kloutsiniotis, 2016a), subjective well-being and workplace burnout (Fan et al., 2014), motivation to continue to work (Schopman et al., 2017) and employee satisfaction (Melián-Alzola et al., 2020).

Many of these employee outcomes are used either as dependent variables or as mediating or moderating variables. A few researchers have adopted well-defined HRM approaches or perspectives like the systems approach (Veld et al., 2010) and the social exchange and economic exchange perspectives (Mihail & Kloutsiniotis, 2016a). Also, the Social Identity Theory has been widely referred to (Bartram et al., 2014; Mihail & Kloutsiniotis, 2016b; Young et al., 2010). Therefore, it can be emphasized that HPWS researchers in the healthcare industry have tried to establish relationships between HPWS–outcomes by incorporating inputs from various kinds of relevant theoretical framework.

The Intervening Variables

In the process of exploring the ‘black-box’ phenomena, HPWS researchers have been investigating ‘employee attitude’ as the mediating mechanism between HPWS-performance and potential outcomes (Kloutsiniotis & Mihail, 2020b). But, in contrast to the HPWS studies that were conducted in other industries, only a few mediators and moderators have been identified in the HPWS healthcare studies. Though some attitudinal and behavioural-related variables were examined for their mediating or moderating role in different healthcare settings, it is understood that there are many other potential variables which have been studied in other industries but are yet to be studied in the healthcare industry.

For example, employee level variables such as perceived organizational support (Liao et al., 2009; Tang et al., 2017), employee discretionary efforts (Cafferkey & Dundon, 2015), customer need satisfaction (Martinaityte et al., 2019), employee motivation (Cafferkey & Dundon, 2015; Kundu & Gahlawat, 2016), employee engagement (Alfes et al., 2013; Li et al., 2019, Muduli et al., 2016), employee morale (Zhang et al., 2013), aggregated service orientation (Aryee et al., 2016), employee self-efficacy (Jyoti & Dev, 2016), intrinsic motivation (García-Chas et al., 2014), leader–member exchange quality (De Oliveira et al., 2015), employee trust (Appelbaum et al., 2000; Kundu & Gahlawat, 2016; Rubel et al., 2018), person to organization fit (Lv & Xu, 2018), psychological capital (Karadas & Karatepe, 2019), employee psychological safety (Miao et al., 2020), presenteeism (Ananthram et al., 2018), service recovery (Karatepe & Olugbade, 2016), job discretion (Chang et al., 2018), manager goal congruence (Zhang et al., 2018), employee resilience (Cooke et al., 2019), learning orientation (Jyoti & Dev, 2016), employee voice (Miao et al., 2020), service behaviours (Luu, 2019), work pressure (Heffernan & Dundon, 2016), job stress (Appelbaum et al., 2000), service-oriented Organizational Citizenship Behaviour (Kloutsiniotis & Mihail, 2020a; Sun et al., 2007), workplace bullying (Page et al., 2018), psychological contract breach (Lv & Xu, 2018), human resource flexibility (Úbeda-García et al., 2018), public service motivation (Luu, 2019), knowledge management (Jyoti & Rani, 2017), job crafting (Meijerink et al., 2020), work intensification (Chang et al., 2018), absence intentions (Karatepe & Olugbade, 2016), etc., can be examined for their mediating or moderating role in the healthcare industry considering the relevance and suitability of a particular variable to the healthcare settings.

Also, the variables at the organizational level like organizational climate (Cafferkey & Dundon, 2015), employee empowerment climate (Aryee et al., 2012), human capital (Ali et al., 2019; Chang & Chen, 2011; Liao et al., 2009; Raineri, 2016), organizational justice (García-Chas et al., 2014; Wu & Chaturvedi, 2009), HRD climate (Muduli, 2015), organizational coordination (Fu et al., 2019), service climate (Lin & Liu, 2016; Wang & Xu, 2017), training transfer climate (Muduli & McLean, 2020), organizational culture (Chow, 2012), social climate (Kloutsiniotis & Mihail, 2020a; Tang & Tang, 2012), employee relations climate (Ali et al., 2019), internal social structure (Evans & Davis, 2005), concern for employees climate (Takeuchi et al., 2009), etc., can be studied in varying healthcare settings.

In previous HPWS literature, it is mentioned that HPWS impacts employee well-being (either physically or mentally or both) in a negative way (Bouville & Alis, 2014; Peccei et al., 2013; Van De Voorde et al., 2012, Wang et al., 2021). The strategic management of human resources in healthcare institutions is important to improve employee well-being in order to deliver high quality of care to the patients (Khatri et al., 2006, 2009; Leggat & Dwyer, 2005; Singer et al., 2009). In previous studies, HPWS researchers have considered specific employee outcomes as employee work-related well-being elements; for example, Zhang et al. (2013), Mihail and Kloutsiniotis (2016a)—emotional exhaustion, work engagement and job satisfaction; Garg and Lal (2015)—employee commitment, job satisfaction, work–life balance; Heffernan and Dundon (2016)—job satisfaction, affective commitment, work pressure in HPWS–outcomes relationship. Some researchers (e.g., Huang et al., 2016) have considered and measured employee psychological well-being while some (e.g., Fan et al., 2014) have studied subjective well-being (life satisfaction, affect balance) also.

In the healthcare industry, only Zhang et al. (2013) and Fan et al. (2014) in Chinese hospitals, and Mihail and Kloutsiniotis (2016a) in Greek hospitals have conducted research and presented a positive relationship in the HPWS–employee well-being link in terms of the social exchange perspective and a negative relationship in terms of the economic exchange perspective. These studies included multiple hospitals (more than five). While majorly large hospitals were considered, so future studies need to be conducted in smaller units of healthcare settings as well. Also, taking the nature of the work into consideration and also as a concern, it can be emphasized that it is extremely important to continuously examine the well-being dimensions in the HPWS–performance relationship, especially in the case of healthcare workers.

Performance Outcomes

An examination of the findings of other industry-related HPWS studies made it clear that there exists a consistent positive relationship between the HPWS and organizational performance. It is also observed that the organizational level performance outcomes for healthcare institutions are different from those of the other industries where patient-level outcomes come before financial outcomes. Among all the studies considered in this study, there are only a few that examined organizational level healthcare performance outcomes.

For example, the quality of patient care and patient satisfaction are considered to be important healthcare performance outcomes (Bartram et al., 2014). But these outcomes were studied only by very few researchers like Gittell et al. (2010), Leggat et al. (2010), Chuang et al. (2012), Baluch et al. (2013), Piening et al. (2013), Bartram et al. (2014) and Mihail and Kloutsiniotis (2016b). Among these, only three studies (Baluch et al., 2013; Gittell et al., 2010; Piening et al., 2013) have collected responses from patients. By highlighting previous research evidence (Cescutti-Butler & Galvin, 2003; Kenagy et al., 1999) on patients’ inability to judge the technical quality aspect of the quality of care, all the other researchers have considered clinicians’ perceived quality of care. Therefore, it is specifically suggested that the data on the actual quality of care be collected directly from the patients in future research studies.

From this finding, it is suggested that future researchers may analyse the actual quality of patient care being provided by collecting responses directly from the patients as proposed by the researchers (Bartram et al., 2009; Bartram et al., 2014; Leggat et al., 2010; Mihail & Kloutsiniotis, 2016b). Researchers can also collect the data on the quality of patient care from both the clinicians and the patients. They can then conduct a comparative analysis to gain insights on the quality of patient care being provided and the quality of care being perceived.

Methodological Concerns

The multiple work levels of respondents (executive, managerial and operational) in HPWS research are highlighted by researchers due to the opportunity they present to analyse the responses on the basis of various study variables. Among the scientific articles reviewed in this study, it is observed that there is an almost equal number of single-level and multi-level respondent studies, 21 and 19, respectively. It is also observed that qualitative study designs have been adopted by HPWS researchers in the healthcare industry. They have conducted structured or semi-structured interviews to gather inputs from the respondents. Among the 40 empirical research papers included in this study, there are 12 published articles based on qualitative analysis constituting 30% of the papers studied. Interestingly, three studies have adopted mixed methods, that is, both quantitative and qualitative analyses to examine the responses from multiple respondents through interviews and questionnaires.

Another interesting observation is that the researchers who have conducted multi-level studies have included respondents from all levels including the executive level (e.g., CEO’s, HR Directors, etc.,), managerial level (e.g., HR managers, administrators, ward managers, clinician managers, line managers, etc.,), and the operational level (physicians/doctors, nurses, front-line healthcare workers, etc.,). Some researchers who examined the patient-level outcomes and administrative issues in the healthcare institutions have also collected responses from the hospital in-patients and government officials, respectively.

To highlight the statistical analysis used by researchers in previous HPWS studies, regression analysis has been used to examine the impact of HPWS on different outcome variables in the initial healthcare studies. Later, the ‘structural equation modelling’ (SEM) and the ‘partial least squares–structural equation modelling’ (PLS-SEM) models have gained prominence and are being consistently used by researchers. Interestingly, it is observed that 12 studies have adopted either SEM or PLS-SEM for statistical analysis. This is in line with the HPWS studies that have been conducted in other industry contexts which also used SEM / PLS-SEM models. Two studies have used the path analysis technique while two other studies have used inductive analysis, which is a statistical technique for conducting qualitative analysis. There are a few studies that conducted moderated-mediation or mediated-moderation analysis using the Hayes Process Macro technique in SPSS.

There is an argument among researchers regarding the treatment of HPWS either as a formative or a reflective construct (Jiang & Messersmith, 2018), and at this point, it is underscored that the use of PLS-SEM is extremely beneficial for HPWS researchers as this is the method that is capable of incorporating formative indicators (Kloutsiniotis & Mihail, 2020b). Based on the theory behind the HPWS, it is suggested that HPWS be considered a ‘reflective–formative’ construct in future studies (Kloutsiniotis & Mihail, 2020b) by first measuring each HRM practice by its reflective indicators and then indicating the relationship between each HRM practice and the HPWS construct as formative (Mihail & Kloutsiniotis, 2016a). Also, as suggested by Kloutsiniotis and Mihail (2020b), in future HPWS studies, it is beneficial to first conduct exploratory factor analysis (EFA) followed by confirmatory factor analysis (CFA) and indicate the model fit indices to confirm robustness of the model. Finally, the identified model can be analysed using PLS-SEM as a reflective–formative construct.

Bibliometric Analysis

A bibliometric analysis was conducted to identify the HPWS phenomena in the healthcare industry over a span of a few years. A statistical software named ‘R’ programming (R studio) version 4.2.1 is used with an internal package named ‘bibliometrix’ installed, which is an R tool for comprehensive science mapping analysis of scientific literature (Aria & Cuccurullo, 2017). All the bibliometric information of the extracted scientific articles was analysed using Biblioshiny, a web application offered for bibliometrix, especially for non-coders.

Keyword Analysis

According to Hu et al. (2018), keywords extraction is an important process when analysing the domain knowledge of a particular research field. In bibliometrics, keywords are the basic elements that represent knowledge concepts and reveal the research domain knowledge structure (Su & Lee, 2010). Keyword analysis not only helps in the effective investigation of the knowledge structure of research domains but also helps in the exploration of developing trends in those domains (Hu et al., 2018). Authors conduct the keyword analysis by identifying the word cloud of the 50 most frequently used author keywords in the studied articles as depicted in Figure 2.

Figure 2.

Word Cloud.

From the word cloud of author keywords, it is observed that the HPWS studies in the healthcare context have largely explored the key performance components of hospitals such as quality of care or quality of patient care and patient safety. Also, some studies explored the relationship between HPWS and employee elements like job satisfaction, work engagement, relational coordination, psychological empowerment, intention to leave, burnout, affective commitment, well-being, etc. The management- and organization-related elements such as transformational leadership, management practices, career ladders, climate and career development have also been studied. Interestingly, with the word ‘qualitative’ placed in the most frequent keywords list, it is observed that qualitative HPWS studies in the healthcare context have also been published.

Once the word cloud of the top 50 author keywords was established, the trend analysis of the HPWS healthcare domain was conducted. Figure 3 depicts the trend topics in the HPWS healthcare industry context from the year 2006 to 2020 with the help of the author keywords with a minimum keyword frequency of 3. It is observed that, in the early stages, keywords like relational coordination, psychological empowerment, nurses, quality of care and job satisfaction have been the most frequent. Later, keywords like employee intention to leave, employee well-being and patient safety were recorded. In recent years, employee elements like affective commitment, work engagement and organizational elements like leadership have been the trending topics that are being explored by researchers. Among all the keywords, the keyword ‘high-performance work systems’ have the highest frequency.

Figure 3.

Trend Topics.

Thematic Analysis

Thematic analysis is ‘a more formal qualitative analytic method that provides a theoretically-flexible approach to analyzing qualitative data’, says Perrin and Liang (2012). A thematic analysis addresses the main themes that were discussed in a research field and the inter-relationships among them (López-Robles et al., 2019). By using the simple centre’s algorithm which is known to be used for co-word analysis, the structuring and grouping of thematic networks can be done as per the frequency of co-occurrence of keywords and as a result, the identification of a set of keyword groups with their connections emerge and these are named as ‘themes’ (López-Robles et al., 2019). According to Cobo et al., (2011), when conducting the co-word analysis for science mapping, a cluster of keywords appears that is termed as ‘themes’. These themes are named motor themes, niche or peripheral themes, emerging or disappearing themes and basic themes. The cluster in these themes is arranged on a 2D graph based on the ranks of centrality on the X-axis and density on the Y-axis. Centrality measures the degree of the strength of the links in the cluster with the other clusters in the network whereas density measures the strength of the links among the words within the cluster (Trinidad et al., 2021). High centrality indicates more importance/necessity of the theme for the research field and vice versa. High-density indicates the high coherence and stableness of associated themes and vice versa.

Motor themes: These are present in the upper right quadrant with high centrality and high-density values indicating the well-developed nature of the theme and its importance to the structure of the research field.

Niche or peripheral themes: These are present in the upper left quadrant with high density and low centrality values indicating well-developed internal ties but unimportant external ties, hence having only marginal importance in the research field.

Emerging or declining themes: These are present in the lower left quadrant with both low density and low centrality indicating their weakly developed ties with the other themes.

Basic or transversal themes: These are present in the lower right quadrant with low density and high centrality, thus indicating the undeveloped nature of the theme. This theme has high importance in the research field.

Authors have conducted a thematic analysis with the author keywords (n = 250; default value of 250 is set as the total author keywords present in the studied articles are less than 250) at minimum cluster frequency and minimum weighing index values set as 5 and 0.1, respectively. The inclusion index weighted by word occurrences is considered as the weight index and a thematic map is generated starting from the year 2006 with 2021 being the cutting year. The number of labels for each cluster is taken as 2 for the clear representation of keywords in the thematic map. Figure 4 depicts the thematic map of author keywords.

Figure 4.

Thematic Map.

In the thematic map, the author’s keywords like ‘human resource management,’ ‘hospitals’, ‘employee behaviours’ and ‘leadership’ are present in the motor theme, which indicates that these clusters are well developed and are important to frame the structure of healthcare industry research. Similarly, keywords like ‘high performance’ and ‘transformational leadership’ are present in the niche or peripheral theme which indicates that these terms have well-developed internal ties but poor external ties in the research domain. Looking at the terms in the Niche theme, we can observe that transformational leadership has a closer relationship with high performance. In the same way, keywords like ‘organizational performance’ and ‘relational coordination’ are in the emerging or disappearing theme. Finally, keywords like ‘high-performance work systems,’ ‘job satisfaction,’ ‘quality of patient care,’ ‘psychological empowerment,’ ‘intention to leave,’ ‘affective commitment,’ ‘well-being,’ and ‘burnout’ are present in the extreme bottom of the basic or transversal theme which has high centrality but low density, thus indicating the ‘undeveloped’ or ‘to be developed’ nature of these clusters and the need for in-depth exploration considering their importance in the research field. There are other keywords such as ‘quality of care,’ ‘nurses,’ ‘patient safety,’ and ‘management practices’ in the basic theme. Interestingly, the keyword, ‘high-performance work practices,’ is also present in the basic theme along with ‘high-performance work systems,’ from which authors infer that the answer to the question, ‘What HPWPs make an HPWS?,’ is yet to be found.

To summarize the findings on the basis of the exhaustive literature review, authors have determined that even though HPWS research is being conducted for nearly three decades, HPWS research in the healthcare industry has made slow progress when compared to the progress made in the manufacturing and other prominent service sector industries. This conclusion has been drawn as there are only a few studies present in the literature. Through this research, authors have shed light on all the empirical and conceptual HPWS studies that were conducted in the healthcare industry to date and elaborated the researchers’ findings of each study. It is seen that researchers have referred to a few theories like the Social Exchange Theory, the AMO Theory, the Contingency Theory, the Organizational Behaviour Theory, the Labour Process Theory and the RBV Theory, among others. Of all the theories used for the study, the Social Exchange Theory has been the most widely cited by researchers in their empirical studies. Also, in the process of exploring the black-box phenomena, researchers have studied some organization level and employee level variables in the HPWS–performance relationship in different healthcare settings. The authors have noticed that when compared to the other industries, there is still a lot of scope left for researchers in the healthcare industry to study many unstudied and understudied variables in different healthcare settings. Another interesting observation made by the authors is that the majority of the empirical studies have been conducted in large specialty hospitals in different countries. Hence, researchers can include other smaller HCOs which contribute as much to the public healthcare system, irrespective of size and strength.

Highlighting the consideration of performance outcomes in the HPWS–performance relationship in healthcare, only a few researchers have studied the organization-level performance outcomes like quality of patient care, patient safety, patient satisfaction, etc. The bibliometric analysis conducted by the authors also gave support to the findings that researchers have majorly concentrated on employee-level outcomes and so there is a need to study the full HR causal chain by including organizational outcomes also. Addressing methodological concerns, authors have identified that researchers prefer to apply the SEM and PLS-SEM techniques from the recent past to conduct multivariate analysis by including multiple independent and dependent variables in their studies. In addition to this, authors have conducted a bibliometric analysis and identified the domain knowledge structure as well as research trends by using author keywords of the reviewed papers. Also, authors have conducted a thematic analysis and addressed the main themes present in the HPWS healthcare research.

Conclusion

With an aim to provide a comprehensive overview of HPWS literature published with reference to the healthcare industry in a systematic manner, the Scopus database was used to identify extant literature published in top journals (ABDC category listed). A critical review of the 45 articles selected was done with an emphasis on understanding how the research has progressed.

From this systematic literature review, it is clear that though there is significant progress in the research on HPWS healthcare, it falls short when compared to the research conducted in other industries. An insightful review of literature discloses there are just a handful of authors who have contributed to HPWS literature in the healthcare industry and the majority of the research has been confined to large HCOs of developed countries. This underscores the dire need of research expansion in the healthcare industry which is crucial and promising and several additional authors may contribute to the studies in the area of HPWS, thus expanding the research in a variety of healthcare settings (e.g., specialty hospitals of varying sizes, aged care centres, teaching hospitals or academic medical centres, laboratories, primary-care centres, etc.) present in different nations across the world, especially in developing countries.

Only a few intervening variables have been examined by researchers in healthcare studies. More number of variables should be tested in different research settings as there might be a significant change in study results with a change in research settings. This helps researchers and practitioners to better understand the phenomena of adoption and implementation of HPWPs in certain healthcare environments.

Hospital management is intricate, considering the nature of the work and the number of different occupational groups that must relate cohesively to ensure high-quality patient care. HPWPs may lead to diverse outcomes for different occupational groups within the hospital. Further research is essential to unfold the multifaceted, causal relationships between employees, occupational groups, HPWS processes, performance outcomes, and the factors that moderate and mediate these relationships. This study underscores a multi-level approach and the importance of examining various performance outcomes of the HCOs from different perspectives, that is, medical practitioners, nurses, hospital administrators, support staff and patients. A multi-level approach can help to operationalize HPWS across different groups of hospital employees and to develop strategies to effectively manage healthcare employees.

Though the authors have conducted an exhaustive review of the articles and presented their findings, there are certain limitations which can be considered to expand the scope for future research. Firstly, authors in this study have reviewed the papers published in ABDC quality listed journals only. Future researchers can review other papers which are published in non-ABDC journals. Second, authors have thought of gaining knowledge of the structure of the research on healthcare HPWS for which, they have applied bibliometric techniques like keyword analysis and thematic analysis. Future researchers can conduct a full-length bibliometric analysis to identify the research breadth of HPWS healthcare studies.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

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