“Human resource management practices and their impact on healthcare workers’ job satisfaction and burnout in the Jordanian public sector”

This study aims to examine the link between human resource management practices and employee outcomes (job satisfaction and burnout) in Jordan’s healthcare public sector, including recruitment and selection, training and development, compensation and benefits, performance management, employee relations, and health and safety. The study utilized a stratified random sample of 600 healthcare professionals. The sample included doctors, nurses, administrative staff


INTRODUCTION
Burnout is a crucial indicator for significant dysfunctions within the workplace, often revealing deeper systemic issues in a given setting (Altun, 2002).Its repercussions extend beyond the immediate work environment, potentially affecting the quality of emotional, technical, and emergency obstetric care provided to women, as well as influencing the health and well-being of maternal healthcare workers.Defined as a persistent negative work-related state of mind, burnout encompasses exhaustion, distress, reduced effectiveness, decreased motivation, and dysfunctional attitudes and behaviors within the work environment (Schaufeli & Enzmann, 1998).This psychological condition evolves gradually from a misalignment between job intentions and realities (Montgomery et al., 2019;World Health Organization, 2018).Job satisfaction, integral to organizational performance, is an individual's holistic sentiment toward their job and their attitudes toward various job aspects (Alrawashdeh et al., 2021;Rotea et al., 2023).It can be described as the attitudes and feelings individuals harbor about their work, where positive attitudes indicate satisfaction (Armstrong, 2006).Job satisfaction significantly influences the alignment between an individual and the organization (Latif et al., 2013;Ivancevich & Matteson, 2002;Spector, 1997).
Human resources management (HRM) plays an integral role in mitigating burnout and determining job satisfaction.HRM is a systematic process directing and controlling employee activities, plays a pivotal role in influencing employee outcomes, including job satisfaction, burnout, performance, engagement, turnover, and overall well-being (Gile et al., 2022), and also meeting organizational objectives and goals (Rotea et al., 2023).It includes policies and strategies to manage people and resources within the organization to meet these goals and objectives (Anwar & Abdullah, 2001).Understanding job satisfaction, reflecting employees' perceptions, is crucial as it directly influences motivation, commitment, productivity, and the quality of care delivered to the public.Therefore, an interaction of these aspects can have cascading impacts on the quality of service and care.
The healthcare sector in Jordan's public sector is the largest employer, facing various challenges, including financial constraints, bureaucratic complexities, political interference, corruption, and nepotism, hindering transparency and accountability (Winkler & Gonzalez, 2019).Moreover, increasing pressures due to population growth, age, urbanization, chronic diseases, environmental issues, refugee influx, COVID-19, and regional conflicts pose additional constraints on the sector's ability to deliver and meet service demands from the public.The healthcare industry is particularly critical and delicate in the public sector.Employing over 35,000 direct and 60,000 indirect personnel, including physicians, nurses, administrators, and support staff, it provides a comprehensive range of care to the population through an extensive network of public hospitals and healthcare centers (The Jordan Times, 2022; Al-Abbadi & Al-Ahliyya, 2021).In addition, the healthcare sector carries the burden of managing the nation's primary healthcare service demands.Considering the above, an essential focus on HRM practices in this sector is critical as it can enhance the work environments in the sector.The impact of HRM practices in the Jordanian healthcare system has not been extensively explored compared to developed nations or other developing regions (Kabene et al., 2006;Dieleman et al., 2009;Gile et al., 2022).

LITERATURE REVIEW
Human resource management (HRM) practices serve as strategic and cohesive measures organizations undertake to effectively manage their most valuable assets -human resources (Mahapatro, 2022).In the healthcare sector, implementing robust HRM practices is indispensable for ensuring the quality and efficacy of health services.Kabene et al. (2006) and Ogbonnaya and Aryee (2021) underscore the pivotal role of HRM practices in cultivating and sustaining a proficient, contented, and dedicated workforce within healthcare settings.Central HRM practices influencing healthcare outcomes encompass recruitment and selection, training and development, compensation and benefits, performance management, employee relations, and health and safety (Delaney & Huselid, 1996).
Recruitment and screening are essential HRM practices for healthcare that determine staff quality and suitability.The goal of this method should be to identify, attract, and recruit individuals with the skills, qualifications, and dedication to provide excellent care.Rotea et al. (2023) state that when recruiting employees, diversity and inclusion in the workplace should also be taken into account, as well as making sure that the ideals and goals of the candidates match those of the company.
Healthcare organizations also use training and development as an HRM strategy to help employees keep learning and advancing.Since medical information and technologies continuously improve, employees must keep their skills and knowledge current.This helps them keep up with changes and gives better care to patients.In addition, training and development programs can help people progress in their careers and help companies retain qualified personnel (Sendawula et al., 2018).
Compensation and benefits are other essential HRM practices influencing qualified personnel's attraction, retention, and motivation.Adequate pay scales and benefits, such as health insurance, pension plans, and allowances, increase job satisfaction and improve employee performance.The fairness, transparency, and equity of compensation and benefits should reflect employees' contributions and achievements (Azmi, 2021) Performance management is a central HRM practice in healthcare, involving routine performance appraisals and feedback mechanisms (White, 2019).This process aids healthcare workers in identifying strengths, addressing weaknesses, and planning for continued career growth.Effective performance management can elevate morale, job satisfaction, and productivity, directly affecting patient care.Performance management's participatory, supportive, and constructive nature involves both managers and employees in goal setting and outcome evaluation.
Two additional crucial HRM practices in healthcare, as emphasized by Rotea et al. (2023), are employee relations and health and safety regulations.Establishing strong relationships and open communication channels fosters a cooperative and respectful environment essential for effective teamwork in healthcare.Ensuring a safe workplace reduces occupational risks, improves staff well-being, and lowers burnout rates.
Recently, people have become more interested in learning how human resource management (HRM) practices affect employee results, especially job satisfaction and burnout (Payne et al., 2020).Job satisfaction, an essential outcome for employees, has got much attention because it results from HRM practices and work settings (Spector, 1997;Chemali et al., 2019;Scanlan & Still, 2013;Çelik & Kilic, 2019).Nishii et al. (2008) showed how good HRM practices, especially those related to fair pay, performance management, and employee relations, significantly affect how happy employees are with their jobs.Additionally, supporting these results, Najam et al. (2020) found that HRM practices positively affect job satisfaction, highlighting that an organization's training and development opportunities significantly contribute to higher employee happiness.Supportive and growth-oriented workplaces make workers more productive and help the company succeed.
The dynamic healthcare industry is characterized by high-pressure demands, heavy workloads, and emotional work from healthcare professionals (Çelik & Kilic, 2019).Healthcare has been the subject of studies on job happiness and burnout (Konlan et al., 2022;Çelik & Kilic, 2019;Kumaş et al., 2019).Job satisfaction is essential in healthcare because unsatisfied healthcare workers can lower patient care levels.The same is true for burnout.The prevalent issue of burnout, characterized by emotional exhaustion, disconnection, and a sense of achievement loss, remains a significant concern in healthcare.Kloutsiniotis et al. (2022) found that HRM strategies that support worker health and safety are essential for preventing burnout.Creating a safe and supportive workplace is critical to prevent burnout, eventually improving healthcare workers' health and safety and leading to better patient care.Furthermore, Oppenauer and Van De Voorde (2018) investigated the connection between HRM practices and burnout.They showed that good performance management lowers burnout.Keeping workers happy and reducing burnout is appreciating their hard work and giving them constructive comments.This becomes vital in a hospital where there is much stress.That is why healthcare organizations must have good HRM practices: these results show how complicated HRM practices can influence how happy and tired workers are.When it comes to healthcare companies, HRM is crucial because it directly affects how well workers do their jobs and how well patients are cared for.Thus, more research is needed, especially in the Jordanian public healthcare system, because it could help make HRM strategies more successful and fit the company's needs.COVID-19 made providing healthcare services worse, putting higher stress on the healthcare system and the employees (Dinibutun, 2020).Alrawashdeh et al. (2021) examined doctor burnout and job satisfaction in Jordan during the COVID-19 disaster and found a link between burnout and factors like gender, working long hours, night shifts, not having enough safety gear, and having SARS-CoV-2.
Additionally, Amer (2021) examined the impact of COVID-19 on burnout and job satisfaction among nurses in Jordanian hospitals.Burnout was attributed to tiredness, depression, anxiety, and overtime, with only a small percentage of nurses reporting satisfaction with their work.These studies show that HRM practices affect Jordanian healthcare workers' performance and well-being, especially during the COVID-19 pandemic.However, more thorough and comparative research on healthcare worker categories, HRM practices, and outcomes like job turnover intentions, organizational loyalties, and patient satisfaction is needed.
The relationship between burnout and work satisfaction must also be acknowledged.Burnout affects psychological performance and behavior, which is linked to job dissatisfaction.Rotea et al. (2023) found a statistically significant link between burnout and job dissatisfaction in Filipino nurses.This shows that healthcare needs complex approaches to identifying and managing these difficulties.The connection between HRM practices, employee outcomes, and healthcare worker wellbeing requires further research and personalized interventions.
To investigate how different HRM practices affect job satisfaction and burnout among health workers in the public sector in Jordan, it is necessary to: • determine the prevalence of burnout among medical professionals in Jordan; • assess perceptions of job satisfaction; • determine the impact of HRM practices on perceptions of burnout and job satisfaction; • identify HR practices that can mitigate or contribute to burnout and job satisfaction.
Answering the above questions can improve Jordan's healthcare system by understanding how human resource management strategies affect job satisfaction and attrition among public sector health personnel.The ultimate goal of the study is to increase the productivity of medical personnel.By addressing the question of whether high emotional exhaustion is an initial symptom or endpoint of burnout, the study aims to guide interventions -preventive or curative -by offering valuable information for organizational improvement.

METHOD
The study employs a quantitative research methodology to probe the influence of HRM strategies and procedures on employee contentment and exhaustion in Jordan's public healthcare domain.Data were collected using a stratified random sampling approach to ensure a good representation of the healthcare professional roles in the public sector.Stratified random sampling separates the population into subgroups or strata based on distinct characteristics (Thomas, 2020).The strata were delineated according to professional roles: administrators, doctors, nurses, and support staff who were from healthcare facilities in the Jordanian public sector in both rural and urban environments.The questionnaires were distributed to 800 healthcare professionals, but only 600 valid responses were used for further evaluation.Following standard sampling processes, participants were invited to the study, and data regarding aims, procedures, advantages, and ethical protections were shared (Bhandari, 2021).Participants could opt out at any point in the study.
The survey was conducted during face-to-face office visits where participants were requested to complete the questionnaire.This approach allowed for immediate clarification of any queries that participants might have had.Upon arriving at the office and acquiring informed consent, participants were handed the printed questionnaire.The questionnaire's initial section underscored the study's objective, voluntary participation, and guaranteed data privacy.It then led to demographic queries before delving into the primary metrics.Each respondent was tagged with a distinctive code to safeguard anonymity during the evaluation phase.Every procedure concerning data handling was executed with stringent adherence to ethical standards, ensuring the participants' privacy and the integrity of research data.

Measuring scales
The HRM scale applied to the Jordanian public healthcare sector was derived from a modified version of Delaney and Huselid's (1996) scale.The scale measures five HRM practices: recruitment and selection, training and development, compensation and benefits, performance management, employee relations, and health and safety.Each practice was assessed via a series of items rated on a five-point Likert scale, from one (strongly disagree) to five (strongly agree).To evaluate burnout, this study employed the Maslach Burnout Inventory-Human Services Survey (MBI-HSS) (Maslach, 1996).This inventory gauges burnout through three key aspects: • emotional exhaustion, measured with nine items focusing on physical and emotional depletion; • depersonalization, assessing negative or cynical feelings about patients with five items; and • personal accomplishment, evaluating self-perceived competence with eight items.
The scales were tailored to the Jordanian public healthcare sector context and involved adjustments after consulting domain experts.The scales underwent professional translation into Arabic using a robust forward and backward translation procedure, with pilot testing conducted among a subset of participants to ensure clarity and cultural relevance.Participants indicated the frequency of their experiences for each item on a seven-point Likert scale, ranging from zero (never) to six (every day).Following findings in the literature, burnout syndrome was defined as high scores on emotional exhaustion and depersonalization and low scores on personal accomplishment (Table 1).The scores of the MBI used in the interpretation are calculated using procedures given in the inventory manual (Maslach, 1996).Note: EE = emotional exhaustion, DP = depersonalization, PA = personal accomplishment.

Data analysis
Frequency distribution, basic statistics, and graphs were used to describe the sample characteristics of the participants in terms of their demographic data as well as responses on the respective scales measured.The basic statistics were computed for each scale, and the mean, SD, minimum, and maximum were included.Cronbach's Alpha was used to compute each scale's construct reliability and validity.An independent samples T-test was used to compare the MBI scores of emotional exhaustion, depersonalization and personal accomplishment by gender and a one-way analysis of variance was used to compare differences by the role of participants.The relationship between age, years of experience, and the MBI dimensions (emotional exhaustion, depersonalization, and personal accomplishment) was assessed using a Pearson correlation analysis.A similar analysis approach was used to compare job satisfaction scores measured by the MSQ scale.
Multiple linear regression analysis was conducted to ascertain the influence of HRM practices on burnout syndrome (as presented by emotional exhaustion, depersonalization, and personal accomplishment) and job satisfaction.The analysis also highlighted the HRM practice factors contributing to or mitigating burnout syndrome and job satisfaction among healthcare workers in Jordan.A correlation analysis was used to establish the relationship between burnout syndrome (emotional exhaustion, depersonalization, and personal accomplishment) and job satisfaction.All data were screened for statistical assumptions and normality before choosing a statistical analysis approach.All analyses were conducted in IBM Statistical Software for Social Sciences (SPSS) version 29.This study used a stratified random sampling approach with a selected participant pool of 800 across the selected strata.A total of 600 participants responded to the survey, with a 75% response rate, cementing the reliability and robustness of the sampling approach.The participant profile had a similar distribution by gender, with females (51.8%) making up a larger number of the cohort (Table 3).Most participants were doctors (28.8%), but there was a similar distribution of administrators, nurses, and support staff (Table 3).The equitable distribution of participants is consistent with using a stratified random sampling technique.The average age of the participants was 41.33(±7.97),with the youngest aged 28 and the oldest aged 55.The average years of experience was 15.11(±7.90),with a minimum of one year and a maximum of 30 years of working experience.

Cronbach
The HRM practices related to recruitment, training and development, and compensation and benefits scores are scored on a five-point Likert scale (one is Not applicable, and five is Always applicable).The participant's responses scored three, which is the neutral response.This suggests that the participants did not fully disclose the impacts of these HRM practices.
For the HRM practices of employee relations and health and safety, participants were asked to respond on a five-point Likert scale (one is Absolutely unimportant, and five is Absolutely important).Similarly, the participants, on average, responded neutrally, suggesting that they did not fully disclose these HRM practices (Table 3).
Participants, on average, show high levels of burnout syndrome, with high emotional exhaustion (EE > 27) depersonalization (DA > 13) and low personal achievement (PA > 39), as Table 3 shows.In terms of job satisfaction, the MSQ score ranges between 20 and 100, with higher scores indicating higher levels of job satisfaction.For general satisfaction, participants scored on average 59.89(±6.25),suggesting moderate levels of job satisfaction.Extrinsic job satisfaction was low (scores below 25), and intrinsic job satisfaction was moderate (scores between 24 and 74).
Overall, participants reported high levels of burnout, with 93.8% reporting moderate to high levels of emotional exhaustion and 93.6% reporting moderate to high levels of depersonalization (Table 4).Regarding personal achievement, 95.2% reported moderate to high levels of personal achievement (Table 4).Prevalence across the three subscales did not differ by age or years of experience (ANOVA P > 0.05).Note: EE = emotional exhaustion, DP = depersonalization, PA = personal accomplishment.
Comparing the relationship between the MBI dimensions, emotional exhaustion showed a moderate positive association with depersonalization (Pearson r = 0.249, p < 0.001).This shows that increasing emotional exhaustion results in increased depersonalization.Emotional exhaustion was not significantly associated with personal accomplishment.Depersonalization showed a moderate negative association with personal accomplishment (Pearson r = -0.248,p < 0.001), showing that increasing depersonalization results in low personal accomplishment.
Burnout syndrome reported in the participants did not differ by gender on emotional exhaustion (t = 0.07, df = 598, p = 0.94), depersonalization (t = -1.08,df = 598, p = 0.278), and personal accomplishment (t = 1.04, df = 598, p = 0.297).When compared among the roles of the participants, there was a significant difference in reported emotional exhaustion among the participants by role (Anova F (3, 596) = 78.97,p < 0.001), Figure 1.Doctors reported significantly higher levels of emotional exhaustion (31.57±6.37) of all the roles, and administrators reported the lowest emotional exhaustion (20.85±6.66) of all the roles (Figure 1).Nurses and support staff did not differ in their reported emotional exhaustion.No significant differences in depersonalization and personal accomplishment were found across all the roles.
There was no significant relationship between age, years of experience, and burnout syndrome, as represented by emotional exhaustion, deperson- Note: n = 600.MBI = Maslach Burnout Inventory; MSQ = Minnesota Satisfaction Questionnaire.
alization, and personal achievements (Pearson r, p > 0.00).Most participants (98.7%) reported moderate levels of job satisfaction and similar levels of extrinsic and intrinsic satisfaction (Table 5).Job satisfaction did not differ significantly by gender for all the subscales of job satisfaction: general satisfaction (t = 0.11, p = 0.910), extrinsic satisfaction (t = 032, p = 0.75), and intrinsic satisfaction (t = 0.09, p = 0.92).Similarly, there were no significant differences in job satisfaction across the various healthcare professionals' roles (Table 6, A NOVA p > 0.05).Pearson correlation was used to explore the relationship between age and job satisfaction, as well as years of experience and job satisfaction.
Although the relationship between general job sat-isfaction and age is negative, and that for extrinsic satisfaction is positive, this was statistically negligible and insignificant (Pearson r = -0.031,p > 0.05 and Pearson r = 0.04, p > 0.05).A similar outcome was found for years of experience and general job satisfaction (Pearson r = -0.04,p > 0.05) and extrinsic satisfaction (Pearson r = 0.05, p > 0.05).Intrinsic satisfaction was negatively associated with age (Pearson r = -0.80,p = 0.05, Figure 2) and years of experience (Pearson r = -101, p = 0.001, Figure 3).
The older the participants and the longer their work experience, the lower their intrinsic job satisfaction (Figures 2 and 3).
Multiple linear regression was used to determine the effects of HRM practice on burnout syndrome, measured as emotional exhaustion, depersonalization, and personal achievements, and job satisfaction, measured as general satisfaction, extrinsic satisfaction, and intrinsic satisfaction.HRM practices influence a range of employee outcomes and are expected to contribute to the participants' perceptions of burnout and job satisfaction.Only general satisfaction was used for the regression analysis as it was highly correlated with extrinsic and intrinsic satisfaction.
The regression model was significant, and the predictors entered into the model could significantly predict the variation in Job satisfaction, ANOVA F (5,599) = 29.265,p < .001.Coefficients showed that employee relations (β = .536,p = .001)and health and safety (β = .450,p < .001)were significant predictors of job sat-   -0.129, p = 0.006) significantly predicted job satisfaction, with 0.13 times decrease when emotional exhaustion increases.Similarly, increasing depersonalization (β = -0.361,p = 0.005) has decreased job satisfaction by 0.36 times (Table 8).A multiple linear regression analysis was conducted to ascertain the influence of HRM practices on burnout syndrome.The regression model with the HRM practices included was significant and explained 40% of the variation in emotional exhaustion (Adjusted R 2 = 0.401; ANOVA F = 9.18, p < 0.01), 24.5% of the variation depersonalization (adjusted R 2 = 0.245, ANOVA F = 7.24, p < 0.001).The model was insignificant for personal achievement (adjusted R 2 = 0.06, ANOVA F = 2.143, p = 0.06).

DISCUSSION
The healthcare professionals reported a high prevalence of burnout, with over 98% showing moderate to high levels of burnout syndrome as measured by emotional exhaustion, depersonalization, and personal achievement.Increased emotional exhaustion was associated with increased depersonalization, while increased depersonalization was associated with decreased personal achievement.Doctors exhibited higher levels of burnout, while administrators showed the lowest.This can attest to the difference in job demands between doctors and administrators.Nurses and support staff had similar levels of reported burnout.
Measuring job satisfaction, participants reported moderate job satisfaction and moderate intrinsic and extrinsic job satisfaction.Job satisfaction was negatively associated with age and  2004) also show that doctors who reported low levels of job satisfaction showed high levels of depersonalization and emotional exhaustion, which supports the findings of this study.Vroom (1964) defines job satisfaction as the harmony between an individual's assigned role in the work environment and the impact of that role within the organization on their perception of their work.Intrinsic job satisfaction involves one's feelings about the inherent nature of the job tasks, while extrinsic job satisfaction relates to how individuals feel about tasks outside the work (Spector, 1997;Hertzberg et al., 1959).According to the two-factor theory, employees have two main types of needs: hygiene and motivation.Hygiene factors, or dissatisfiers, encompass supervision, interpersonal relations, physical working conditions, salary, and benefits.Conversely, motivation factors are jobrelated.Gupta and Woldemariam (2011) distinguishes job satisfaction from motivation and morale, where motivation reflects the willingness to work, job satisfaction implies a positive emotional state, and morale signifies a general attitude toward work and the work environment.Healthcare human resource practitioners, policymakers, and managers must be cognizant of this and develop appropriate strategies for managing healthcare workers and enhancing their work environment.Moreover, there is a need to understand that the development of burnout and job satisfaction are critically linked to HRM practices and that practitioners should focus on understanding and preventing the factors contributing to burnout and job dissatisfaction.

Figure 1 .
Figure 1.Differences in reported emotional exhaustion (Mean±SD) by the role or position held by the healthcare professionals

Figure 2 .
Figure 2. Relationship between age and intrinsic job satisfaction clustered by gender and role

Figure 3 .
Figure 3. Relationship between years of experience and intrinsic job satisfaction clustered by gender and role isfaction among the participants.Regarding HRM practices, an increase in positive employee relations results in 0.54 times increase in job satisfaction, and an increase in health and safety results in 0.53 times increase in job satisfaction (Table7).The effect of burnout on job satisfaction was also assessed using a linear regression analysis.The significant model explained 36.7% of the variation in job satisfaction (adjusted R2 = 0.367, ANOVA F = 11,233, p < 0.01).Emotional exhaustion (β =

Table 1 .
Maslach burnout inventory scores for interpretation purposes

Table 2 .
Validity and internal consistency of the MBI and MSQ scales (Maslach & Jackson, 1981d tool to measure the internal consistency, validity, and reliability of scales.The appropriate values should be above 0.7 for the scale to have consistency in reliability and validity.Cronbach's Alpha scores for the MBI and MSQ (Table2) were all above 0.7, showing high internal validity and reliability, consistent with previous findings(Maslach & Jackson, 1981; Stodel & Stewart-Smith, 2011; Sirsawy et al., 2016).

Table 4 .
Prevalence of burnout among the healthcare professionals

Table 5 .
Degree of job satisfaction among healthcare professionals in the Jordanian public sector

Table 6 .
ANOVA results comparing differences in job satisfaction by role of healthcare professionals

Table 8 .
Regression coefficient: Effect of burnout on job satisfaction

Table 7 .
Regression coefficients: Effect of HRM practices on job satisfaction

Table 9 .
Elit et al. (2004)22)3)) Effect of HRM practices on burnoutScanlan and Still (2013)have also hinted that individuals with high levels of depersonalization are emotionally disconnected from their workplace environment.This means low job satisfaction and a high prevalence of burnout will increase depersonalization manifestation, which is dangerous in the healthcare sector as it threatens patient care.In addition, low depersonalization can lead to increased intention to leave(Scanlan & Still, 2013), further threatening the healthcare sector.Emotional connection, sensitivity, and care are essential to quality healthcare(Samadi et al., 2023).The prevalence of burnout was high among doctors, but job satisfaction did not differ across the roles studied: it was moderate for all roles.Doctors' and nurses' work demands and responsibilities are significant, and they face extensive pressure within their work environments.Heidari et al. (2022)reported a high prevalence of emotional exhaustion and depersonalization and a low in the study cohort of nurses.Moreover, high burnout lowers job satisfaction and increases depersonalization, ultimately leading to feelings of poor personal achievement.Elit et al. (2004)also reported a high prevalence of burnout among doctors, coupled with high depersonalization and low levels of personal achievement.However, the study indicated that job satisfaction was moderate to high, attributing this response to workplace-related characteristics.Elit  et al. (