“Measuring the antecedents of turnover intentions: Perspectives of private healthcare employees in a less-developed economy”

This study sets out to investigate the antecedents of turnover intentions, using the private healthcare employees in an emerging economy (Ghana) as a benchmark. Even though myriad studies have been conducted on the aforementioned topic, yet, there are scant investigations on how employees of private healthcare institutions relate towards turnover intentions, specifically in a developing economy context. Therefore, this study draws on extant literature and subsequently proposes a hypothetical argument on the effect of training satisfaction, benefits and incentives on employee turnover intentions as well as resistance to change while establishing the nexus between turnover intentions and resistance to change. Both paper and web-based (online) questionnaires were gauged from employees of private healthcare organizations in Ghana. Data were analyzed by partial least square structural equation modeling (PLS-SEM) on a sample of 544 employees of private healthcare institutions. The findings indicate that training satisfaction, benefits and incentives have a positive impact on an employee’s turnover intentions. Moreover, employee’s resistance to change is influenced by both training satisfaction and benefits and incentives. Further, the investigation established that employee’s resistance to change influences employee turnover intentions. The thoughtful mechanisms of how the running of private healthcare institutions in Ghana can be enhanced are expanded by the empirical results obtained through how employees can be satisfied by training and the application of rewards to reduce turnover. Moreover, administrators of private healthcare organizations are forewarned of the implications of employees’ resistance to change and its effect on employee turnover intentions.


INTRODUCTION
The most exclusive and treasured asset which requires effective investment in any entity is its human capital (Wang et al., 2020).The ability to attract qualified employees and talent to build a competitive advantage serves as very vital for the success and sustainability of every organization (Wang et al., 2020).In contrast, high-quality healthcare professionals in emerging economies do not find the private healthcare industry very attractive (Bhattacharyya et al., 2010) due to myriad limitations such as low wages, little or no career progression (Anderson et al., 2017), and high physical and emotional stress (McKerrow et al., 2020).In effect, many newly graduated healthcare professionals in Ghana consider the private healthcare industry as a temporary measure to gain more experience and subsequently, enroll in the public healthcare sector with the least opportunity (Kingma, 2017).According to Grabner-Kräuter et al. (2021), the perception about private healthcare employees' training in emerging economies leads much to be desired, this phenomenon breeds increasing turnover intentions amongst employees in the private healthcare sector.Graduates within developing countries do not see private healthcare industry jobs as a high social status job (Davis & Binder, 2019).The healthcare industry is thriving worldwide and demands more healthcare professionals, nonetheless, inadequate funds and lack of resources hinder its overall function and improvement in emerging economies (Kingma, 2017).
Due to the growing number of healthcare graduates in emerging economies, it is imperative for managers of private healthcare institutions to develop strategies that absorb their employees in the mix of the meager resources available to them.However, private healthcare institutions in developing countries experience frequent turnover (Kingma, 2017).This study makes at least three vital contributions.
First, this study advances on the extant literature to expand and reframe the evolving works besides contributing to the developed countries' dominated debate on private healthcare industries and employee turnover intentions.
Second, considering the increasing scholarly interest in understanding the antecedents of turnover intentions, this study provides managers and supervisors with the strategic jigsaw to connect the essentials of the need to reduce turnover.
Third, practical input is made by gathering primary data from healthcare workers from sub-Saharan Africa (Ghana) and structural equation modeling (SEM) and path-coefficient techniques are used to test the proposed model.
Hypotheses were formulated out of the research model depicted in Figure 1 and subsequently tested.The aim and a methodological procedure that details the data collection process are also elaborated.Results, discussions, and finally the conclusions are expounded.

Private healthcare industry in emerging economies
The sector of any general economy possessed, controlled, and managed by private individuals and enterprises is described as the private sector (Netzer, 2020).Even though the main objective of the private sector is to make a profit (Amarasiri & Dorabawila, 2018), nonetheless, private sector in most economies employ a chunk of the human resource available compared to the public sector (Armstrong & Taylor, 2020).Some countries especially free economies develop deliberate policies to privatize public sector organizations (Mikic et al., 2020).
Generally, the private healthcare sector is made up of hospitals, clinics, and pharmacies, which run independently from the National Health Service's control and direction (Kingma, 2017).They are typically run by a commercial organization, although some may be run by charities or other non-profit organizations (Netzer, 2020).However, private healthcare employees in emerging economies crave to move to the public healthcare sector (Kingma, 2017), because of the quest for job security, good condition of service, better pay, excellent training opportunities, etc.Since private healthcare institutions are susceptible to all manner of government and external shocks, it oftentimes limits their ability to provide their employees with these benefits (Mikic et al., 2020).
Nonetheless, private healthcare employees like any other employee require frequent training sections to catch up with modern caregiving (Idei & Kato, 2020).In addition, there is an influx of private healthcare facilities in developing countries due to the emergence of numerous healthcare employees vis-a-vis the lack of enough public healthcare facilities to absorb them afterward (Timmons et al., 2016).Moreover, there are unfavorable eco-nomic conditions that impress on governments in developing countries to decrease the employment of qualified healthcare workers even though their services are required in various communities (Idei & Kato, 2020).

Private healthcare employees resistance to change
Organizational change refers to the actions in which a company or business alters a major component of its organization such as its culture, the underlying technologies or infrastructure it uses to operate, or its internal processes (Warner & Wäger, 2019).Even though a change in the organization is constant nonetheless, it is complex and often impulsive.Whereas it is very difficult to implement change in organizations (Burke, 2017), employees refuse to change on numerous grounds, which include the habit of the employees themselves, non-existence or ineffective communication, the fear of the unknown, lack of safety economic considerations, and organizational culture (Warner & Wäger, 2019).However, the success of change management in organizations that relies on the structure, availability of resources, ideas, and tasks of the organization and ignoring the preparedness to work towards the change-related goals by employees can be detrimental (Metwally et al., 2019).Anxiety about job stability has an overarching effect on employee's acceptance to change (Srivastava & Agrawal, 2020).Break-in communication is also another change-resistant factor amongst employees in the organization thus organizational needs, benefits, and drawbacks are mostly discussed by employees affected by the pending or ongoing change (Metwally et al., 2019).
In effect, organizations must adapt to prevailing changes in the competitive market conditions, nevertheless, change must be cost-effective and fruitful (Srivastava & Agrawal, 2020).Moreover, organizations will have a greater opportunity to avoid major pitfalls in connection with the change, with the ultimate understanding of factors that impede the development of change management (Busari et al., 2020).Even though researchers and organizations continually find it foremost challenging to identify resistance to change, yet employees need inclusive information about the nature, processes, and consequences of organizational change (Metwally et al., 2019).Moreover, these attributes are not just important to prepare employees for change and overcome resistance, but it also provides readiness and makes employees active contributors to the accomplishment of change (Busari et al., 2020).

Organizational benefits and incentives for private healthcare employees
According to Reddy (2020), to attract and keep the best employees, organizations provide a "compendium" that includes compensation (money), incentives (special perks or rewards for good work), and benefits.Most employers enjoy the respect of their employees by providing enticements and benefits as a reward for good work done (Jaworski et al., 2018).Unfortunately, it is well known in the private healthcare business in emerging economies benefits and enticements are very scanty (Reddy, 2020).Myriad literature in human resource management and organizational behavior confirms that incentives serve effectively as a motivation for employees (Jaworski et al., 2018;Ormel et al., 2019).The crux of enticements is to establish linkages that will make employees feel appreciated (Ormel et al., 2019).
Enticements play a substantial role in the perception of the reward climate in a working environment (Ormel et al., 2019).Moreover, employees perceive organizations to be very supportive and caring when they receive enticements (Jaworski et al., 2018).As a result, some of the most important incentives and benefits that increase the attachment of an employee to an organization are recognition, promotion, and responsibilities (Cassar & Meier, 2018).
According to Acheampong (2019), private healthcare workers in emerging economies have a penchant for quitting their jobs, exhibiting low organizational commitment compared to their counterparts in the public sector.The short-term demerits of private healthcare workers' turnover are the repetitiveness of time wastage in consistently hiring and training new employees results in decreased quality of service, reduction in clients' attendance, and ultimately loss of revenue in the long term (Jaworski et al., 2018).Studies concerning training, benefits and incentives of healthcare industries especially in the emerging economies are scanty in literature.The following propositions were developed with the literature in mind.

AIMS AND HYPOTHESES DEVELOPMENT
This study aims to investigate training satisfaction, benefits and incentives on turnover intentions in private healthcare institutions in emerging economies.Additionally, the study aims to determine how resistance to change can be curtailed by employee training satisfaction and benefits and incentives amongst private healthcare staff.The paper seeks to explore the relationship between turnover intentions and resistance to change.The aforementioned goals are basically dependent on the purview of the lack of empirical studies of private healthcare employees in emerging economies (Kingma, 2017).Most importantly, the study tries to shed more light on the activities of private healthcare institutions and their functions within emerging economies.Figure 1  H4: Resistance to change has a significant relationship with turnover intentions.
H5: Benefits and incentives positively influence turnover intentions.

Data sampled and demographics characteristics
To measure the relationships amongst latent variables the study used a quantitative research approach, using partial least square structural equation modeling (PLS-SEM) version 3. The decision to use the private healthcare employees was because the private healthcare industry is not well developed when compared to the public healthcare industry and again, they are not as resourced as public healthcare facilities.Moreover, the private healthcare industry provides the best platform in tandem with the objectives of this study.
To easily reach the targeted population, a convenient sampling technique was adopted, while a random sampling technique was adopted to get the data from the employees of the private health care professionals via paper-based questionnaires.The technique became necessary due to the willingness of the respondents to make available the needed information (Etikan & Bala, 2017; Watanabe et al., 2014).The data collection occurred between April-June 2021.All COVID-19 protocols were adhered to (in the course of the self-administration of the questionnaires).Whereas 660 questionnaires were administered, 600 (90.9%) responded to the data processing and analysis.Nonetheless, 544 (90.7%) were answered correctly for the data analysis.A 5 minutes average was needed for each respondent to complete the items on the questionnaire.Readers must take note that for confidentially and ethics sake, the questionnaire was set out as anonymous.Table 1 summarizes the profile and data of the respondents.

Measurement of the constructs
An average of five items was selected for each construct under scrutiny.A five-point Likert was adopted to measure all the items.The five-point Likert scale ranged from strongly disagree to strongly agree (1 -strongly disagree, 2 -disagree, 3 -neutral, 4 -agree, and 5 -strongly agree).In collecting the data, the items for the measurement of the training satisfaction and organizational benefits and incentives were adapted from

RESULTS
In testing the hypothesis, partial least square structural equation modeling (PLS-SEM) smart-PLS version 3.0 was used.PLS-SEM was preferred to CB-SEM with the reason being that CB-SEM and PLS-SEM use different approaches when assessing the quality of a structural model.For example, with CB-SEM, the fit is based on accurately estimating the observed covariance matrix, while with PLS-SEM, the fit is based upon accounting for explained variance in the endogenous constructs (Hair Jr et al., 2014), depicted in Figure A1.

Model measurement
To significantly assess the construct reliabilities, PLS-SEM was seen to be appropriate.Therefore, Cronbach's alpha and composite reliability were used to determine these reliabilities ( ).The composite reliability of the constructs with a minimum threshold of 0.7 met the requirement for the analysis.The available results confirm minimum reliability of 0.761 and 0.850 of Cronbach's alpha.The average mean extracted (AVE), which shows convergent validity is at par with the minimum threshold of 0.5 (Table 3).
The latent variables were loaded and assessed carefully in tandem with each variable based on the recommendations of Bagozzi and Yi (1988).All the loadings factor loadings were above the threshold of 0.5 as exhibited in  For the assessment of the significance of the discriminant validity of the constructs and that of the latent variables, the Fornell-Lacker criterion was adopted (Henseler et al., 2015;Hilkenmeier et al., 2020).As depicted in Table 5, of the Fornell-Lacker criteria the recommendations (Henseler et al., 2015;Khan et al., 2019) are illustrated in bold, in a diagonal and are above the threshold of 0.5.

Structural modeling path breakdown
The need for path analysis emanates from the model fit.The function of the path coefficient is to determine the link between the research constructs.The output of the data suggests that training satisfaction (TS) and benefits and incentives (B&I) have a positive influence on turnover intentions (TI) and resistance to change.This confirms all the research propositions set out for this study.
In addition, the relationship is displayed in Table 6 that contains Beta (β), T-statistics, P-values, standard deviation, the sample mean, etc.

Implications
The research objectives were three-fold: (a) to determine the effect of training satisfaction and benefits and incentives on turnover intentions, (b) to determine the impact of training satisfaction and benefits and incentives on resistance to change, and (c) to determine the link between turnover intentions and resistance to change.Satisfaction of training, benefits and incentives are perceived to be valuable in reducing turnover intentions and relaxing the resistance to change of private healthcare employees in developing economies.This study augments scant literature on the relationship between training satisfaction and benefits and incentives on turnover intentions and resistance to change in the private healthcare industry and specifically in the Ghanaian private healthcare industry.This exploratory study arguable is the first study to link training satisfaction and benefits and incentives with turnover intentions and resistance to change by employees specifically in the private healthcare industry.
Again, this study explores the relationship between turnover intentions and resistance to change.The initial conclusion of this study, with the fulfillment of the first part of the objective of the study, satisfies the initial part of the purpose of the study thus hypothesis one (H1) is confirmed: training satisfaction has a significant relationship with turnover intentions.Grounded on the responses from the employees of private healthcare employees in Ghana, results from the study aligns with the views of Srivastava and Agrawal (2020) who report that training has a significant effect on employee turnover intentions.Therefore, private healthcare industries must reconsider the cost of not providing training for their employees by reinvigorating the culture of providing training (Huang, 2019).Zarychta et al. (2020) recommend that private healthcare employees deserve the same training given to their counterparts in the public sector and this broadens their perspective and minimizes turnover intentions concerning private healthcare.Employees are specifically satisfied with their training when their favorite choice of training methods is used (Armstrong & Taylor, 2020).Training costs can be reduced by the adaptation of specific training regimes for example one-on-one training (Jaworski et al., 2018).Whereas the trainees get to execute their task at little or no cost at all, the trainer gets first-hand information about the competence of the trainee (Spooner et al., 2019).The second part of the first objective of the study also satisfies hypothesis five (H5): benefits and incentives significantly influence turnover intentions, which corroborates the assertions of Reddy (2020) who report a significant negative relationship between benefits and incentives and employee turnover intentions.According to Reddy (2020), there are scant resources in the private healthcare industry in a developing economy particularly with regards to how benefits and incentives affect employee turnover intentions.This scant in this context limits the sector managers' ability to institute relevant organizational practices that will counteract the high attrition rate among private health employees (Rahman & Al-Borie, 2020).
The second conclusion, which addresses the first objective, confirms hypothesis two (H2): training satisfaction has a significant and positive relationship with resistance to change.Thus, the more satisfied employees are with their training regimen, the less resistance they exhibit towards organizational change.Reasons that prompt employees to sabotage change in organizations may be attributed to myriad factors such as, fear of job loss, anxiety about the unknown, ).To fulfill the second objective, which is the effect of benefits and incentives on resistance to change results from the study reveal that benefits and incentives have a positive relationship with resistance to change which also confirms hypothesis three (H3).This implies that the success of change management in any organization relies on its structure, availability of resources and rewards to persuade the willingness of employees to work towards change-related goals (Busari et al., 2020).According to Nielsen et al. (2019), even though, change must be cost-effective, it must also be carried out with a proper reward scheme where the expected benefits employees may derive from the new change that can be used as the freezer.Even in situations where benefits and incentives are scanty, managers must do well to make it available to entice their employees to guarantee positive change (Ormel et al., 2019).
The conclusion of the study addressing the third research objective to determine the link between resistance to change and turnover intentions satisfies hypothesis four (H4): resistance to change has a significant influence on turnover intention.It is well known that the more employees resist change in an organization the more they contemplate quitting their job (Peltokorpi et al., 2015).Human measurement is the most important element in change management.Whereas change has been vastly explained in literature as from the known to unknown, organizations may be able to galvanize support from their employees when there is sufficient reason that the new change will result in better economic gains both for the employer and employee (Srivastava & Agrawal, 2020).Evidence of resistance to change often emanates from the behavior and the conduct of employees to maintain the status quo (Srivastava & Agrawal, 2020).In contrast, lack of cooperation and lack of proper communication to employees in altering the status quo can lead to a surge in turnover intentions (Abugre, 2017).In spite, of the myriad of investigations into turnover intentions, there has not been a specific model or antecedents to unravel the reason for turnover (Srivastava & Agrawal, 2020).This revelation confirms hypothesis four (H4): employees can experience shock which is a single event that triggers turnover.This event or shock is the reason for an individual intention to voluntarily leave their organization (Yang et al., 2020).According to Srivastava and Agrawal (2020), shock is vital to rekindle the enthusiasm of employees from their inertia, which makes it possible to scrutinize the connection between resistance to change and turnover intentions.
The previous study has elaborated resistance to change as one of the main reasons for the failure of change implementation in organizations (Srivastava & Agrawal, 2020).The chance of survival after a change procedure in an organization is dependent on high costs, which breeds failure.The undefined new situation after an organizational change will need moving from apathy and may result in negative feelings for the organization.Employees' intention to quit will be a product of resistance to change.Therefore, when employees resist change, then there is a greater possibility to leave their employment (Raza et al., 2018).

Limitations and future research
Notwithstanding this study's contributions to literature, a few limitations need to be kept in mind, necessitating future research considerations.First, the study was conducted in sub-Sahara Africa, Ghana to be precise.This does not reflect the entire world of emerging economies.Therefore, the study cannot be wholly generalized based on the sample size and the geographical location.Therefore, a different location will be conducive to affirm these relationships.
Second, employees of private healthcare were the focal point of this study nonetheless future studies can be conducted on public sector employees.Again, future studies should investigate the perspectives of managers and supervisors who run these private institutions in emerging economies.
Third, it was statistically conspicuous, that the fitness of the model used for this analysis indicates that the model was suitably used for its projected purpose.Nonetheless, like all empirical investigation, stratified random sampling was adopted for the study even though a non-probability sampling particularly convenient sampling could have been properly used for the data gathering.
Fourth, the study is based on cross-sectional studies.Hence, future studies employing longitudinal research design and data gathering in the different backgrounds could go a long way to validate and reinforce the findings.

CONCLUSION
The study proposes a training satisfaction, benefits and incentives, resistance to change, turnover intentions (TOI)-model and use primary data from employees of private health care institutions in sub-Saharan African country Ghana to empirically examine the effect of training satisfaction, employee benefits and incentives on TOI and the link between TOI and resistance to change.Evidence from the study reveals that there is an effect of training satisfaction, benefits and incentives on both turnover intentions and resistance to change.Additionally, the study confirms that turnover intentions are influenced by resistance to change.The current investigation develops the understanding that private healthcare employees in developing economies do not harbor an intention to quit when they are satisfied with their training regime.Moreover, it should be noted that change is constant, yet, when mismanaged, it can have a dire consequence on the turnover intentions of the organization.It is essential for managers and supervisors of private healthcare organizations in developing economies to reorganize that training satisfaction, rewards, and proper change management are the magic to keep their employees.
represents the conceptual model of the study.The study develops the following hypotheses: H1: Training satisfaction significantly influence turnover intention.H2: Training satisfaction significantly influence resistance to change.H3: Benefit and incentives significantly influence resistance to change.

Figure 1
Figure 1.Conceptual framework Literature sources Training satisfaction (TS) I am satisfied with the training regime in my institution Jaworski et al. (2018) I am satisfied with the training method I am satisfied with the managements attitude towards training I am satisfied with the impact of training on my job performance I am satisfied with the periodic training regime In contrast, CB-SEM is with confirmatory research where the goal is to test a theory (Hair Jr et al., 2020).As cogently advocated by Hair Jr et al. (2017) and Shiau et al. (2019), the variance of the latent variables was fully explicated by this software.Again, one of the merits of PLS is its exploratory abilities, hence, the pru-dence to adopt for exploratory studies.Lastly, measurement and hypothesis were carried out by smart-PLS software version 3.3.3.

Table 1 .
Demography and characteristics of the respondents

Table 2 .
Construct indicators and literature sources Source: Authors' elaboration.

Table 4 .
The common method vari-

Table 3 .
Construct reliability and validity

Table 6 .
Hypothetical path coefficient