Journal of Tourism, Hospitality, and Services Industries Research (JTHS) Volume 4, No.

1, June 2024

Volume and Issues Obtainable at the Department of Tourism and Hospitality Management-
The Islamia University of Bahawalpur, Bahawalpur, Pakistan 63100.
Journal of Tourism, Hospitality, and Services Industries Research
ISSN: 2958-5570 ; ISSN (E): 2958-5589
Volume 4, No.1, June 2024
Journal homepage: [Link]
DOI: 10.52461/jths.v4i01.2811

Role of Ambidextrous Leadership in Enhancing Work

Engagement and Organizational Performance.
Waseem Rafiq, Department of Management Sciences, Alhamd Islamic University, Islamabad, Pakistan
Noheed Khan*, Department of Management Sciences, Alhamd Islamic University, Islamabad, Pakistan
ARTICLE DETAILS ABSTRACT

History This empirically examined the role of ambidextrous leadership on

Received Feb, 2024 employees’ work engagement and organizational performance.
Online: June, 2024 Ambidextrous leadership encompasses a leader’s capability to stimulate
Keywords exploitative and explorative activities in employees. A cross-sectional
Ambidextrous leadership, High survey was developed, and data were gathered through convenience
performance work systems,
Exploration, Exploitation, Work sampling of N=258 health professionals from government and private
engagement, Organizational sector hospitals from main cities in Pakistan with a condition to have
Performance, Health professionals,
Home-care services
COVID emergency response centers in them so that pressure and crisis
management experience must be there in the population of study. The
study’s conceptual model was analyzed through structural equation
modeling partial least squares with SmartPLS 3 software. Mediation by
bootstrap was used to analyze the indirect relationships. Results
Ambidextrous leadership was found to have a direct impact on both work
engagement (β = 0.236) and organizational performance (β = 0.395). The
direct relationship between ambidextrous leadership and employee
creativity was nonsignificant. However, the relationships between
ambidextrous leadership and work engagement and organizational
performance were both mediated by High performance work systems.
Finally, the results reveal that organizational performance mediated the
relationship between high performance work system and work engagement.
The results show that ambidextrous leadership and high performance work
system promote the overall performance of health professionals. Thus, a
practical implication is that health-care organizations should recruit, train,
and develop their leaders to become ambidextrous leaders, in addition to
being aware of the multiple direct and indirect effects of practicing
ambidextrous leadership.

© 2024 The authors, under a Creative Commons Attribution Non-

Commercial 4.0

*Corresponding author: noheed_khan@[Link]

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Journal of Tourism, Hospitality, and Services Industries Research (JTHS) Volume 4, No.1, June 2024

INTRODUCTION
The healthcare system in Pakistan is confronted with multiple challenges that hinder its ability to
deliver equitable and effective medical care. Key issues include disparities between public and
private healthcare services, with public hospitals often lacking essential services and private
healthcare being financially inaccessible for many (Shaikh & Hatcher, 2005). Despite increasing
health expenditures relative to Pakistan's GDP, there has not been a corresponding improvement
in crucial health indicators such as life expectancy, infant mortality, and healthcare service quality.
This discrepancy highlights the need for a thorough examination of the system’s efficiency and
resource allocation. Literature has revealed that there is need for further investigation into
Pakistan's healthcare system could focus on several critical areas:
i. Resource Allocation: An analysis of how financial resources are allocated and utilized
within the healthcare sectors could highlight inefficiencies or misallocations (Shaikh
& Hatcher, 2005).
ii. Infrastructure Development: Improvements in both physical infrastructure and the
integration of advanced health management technologies are needed to enhance
service delivery in public hospitals.
iii. Human Resources: Addressing the shortage of healthcare professionals is vital.
Policies aimed at increasing training, retention, and equitable distribution of health
workers must be developed.
iv. Healthcare Accessibility: Exploring barriers to accessing healthcare, especially in the
private sector, could help in formulating policies to make healthcare more affordable
and equitable across different population segments.
v. Policy and Governance: Assessing the governance mechanisms of healthcare
provision could identify necessary policy adjustments to improve health service
delivery effectiveness.

The general overall situation of Pakistan’s healthcare sector can be seen in table below:
Table1: Healthcare Sector of Pakistan at Glance
Domain Facts Source
Healthcare Healthcare spending has varied from 0.5% to 0.8% of GDP over the (Khan, 2019)
Expenditure past ten years, which is below the 6% recommended by WHO
Policy Changes Recent years have seen policy initiatives guided by the Alma Ata (Ali et al., 2021)
Declaration, with an emphasis on Primary Healthcare (PHC)
Rural Population Basic healthcare services reach approximately 70% of the rural
Coverage population
UN Healthcare Aims to achieve compliance with UN healthcare standards by 2030
Benchmarks
Number of Healthcare There are about 17 programs currently, which include both vertical
Programs and horizontal integration efforts
Notable Initiatives Key programs include the National Tuberculosis Control Program
and the Lady Health Worker (LHW) Program
Infrastructure Healthcare infrastructure is insufficient, from a scarcity of hospitals (Khan, 2019)
Challenges to uneven distribution of facilities
Current Healthcare Current healthcare spending is at 0.4% of GDP, significantly under
Expenditure the WHO's guideline for low-income nations
Workforce There is a shortage of trained nurses and an inadequate doctor-to- (Health workforce profile of
Challenges patient ratio Pakistan, 2020; Khan, 2019)
Innovative Financing Public-private partnerships like the Sehat Sahulat Program initiated (Hasan et al., 2022)
Models in 2015 are promising but face challenges

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These areas represent a comprehensive approach to reforming the healthcare system in Pakistan,
aiming to ensure better accessibility and quality of healthcare services for the population. Among
these the work engagement is major challenge for effective performance outcomes. Leadership
style has been widely recognized as a pivotal element in enhancing organizational performance
and work engagement, particularly within the healthcare sector. Research indicates that the
effectiveness of leadership can significantly influence both the individual and collective outputs
of healthcare professionals (Al-Sawai, 2013). The integration of high-performance work systems
(HPWS) further amplifies this effect, providing a structured environment in which leadership
styles can more effectively impact employee outcomes (Boon et al., 2019). Leadership is
recognized as a pivotal factor across various organizational types, with a particular emphasis on
its significance in enhancing work engagement within healthcare settings (Leadership Academy,
2020). It is imperative to advance our comprehension of leadership's multifaceted impacts within
healthcare organizations. This research primarily investigates the concept of ambidextrous
leadership, defined by its dual focus on explorative and exploitative practices, and its correlation
with work engagement among health professionals (Rosing et al., 2011). Furthermore, the study
probes the potential of ambidextrous leadership to influence indirect health-related outcomes,
evident in enhancements in high performance work systems and overall organizational
performance (Birkinshaw & Gibson, 2004). Given the comprehensive influence of leadership on
various organizational dimensions and individual performance, it is essential for organizations,
particularly in healthcare, to delineate and understand the nuances of effective leadership practices
(Zhang et al., 2015). The given study is an effort to substantiate the issue of in effective human
resource depletion and their respective engagement due to leadership inefficacy.
Ambidextrous leadership, which involves the capability to flexibly switch between explorative and
exploitative leadership behaviors, is particularly effective in healthcare settings where both
innovation and efficiency are required (Rosing, Frese, & Bausch, 2011). This style allows leaders
to foster innovation (exploration) while simultaneously managing daily operations efficiently
(exploitation), thereby enhancing work engagement and organizational performance (Zacher &
Rosing, 2015).
Moreover, the presence of HPWS systems that enhance employee capabilities through
comprehensive training, development, and decision-making autonomy—has been noted to
synergize with ambidextrous leadership to promote enhanced organizational performance (Jiang
et al., 2012). This interaction suggests that when leaders effectively balance and exhibit both
explorative and exploitative behaviors, they enhance the organizational commitment, work
engagement, and overall performance of healthcare employees (Birkinshaw & Gibson, 2004).
In sum, ambidextrous leadership profoundly impacts the performance and engagement of
healthcare workers, particularly when aligned with HPWS. The efficacy of ambidextrous
leadership in fostering an environment that balances innovation with operational efficiency
underscores the need for strategic leadership development within healthcare institutions (Kuoppala
et al., 2008).
This research focuses on the healthcare sector in Pakistan, specifically targeting health
professionals employed in both government and private sector hospitals that have designated
COVID-19 emergency response centers. The study is designed to capture a comprehensive cross-
section of healthcare professionals, encompassing various roles and responsibilities within these
organizations, thus providing a broad perspective on leadership dynamics in high-pressure
environments. The investigational framework employs a cross-sectional survey method to gather

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data, enabling the analysis of current perceptions and behaviors related to ambidextrous leadership
and its effects.
The analytical approach is grounded in structural equation modeling (SEM) using SmartPLS 3
software, which is well-suited for complex model testing including mediation effects, thereby
providing robust insights into the relationships among ambidextrous leadership, high performance
work systems, work engagement, and organizational performance. The study’s geographical and
sector-specific focus, combined with advanced statistical analysis, delineates its precise scope
within the realm of organizational behavior and healthcare management. This study addresses
significant gaps identified in prior research by focusing on two primary objectives. Initially, the
study investigates the influence of ambidextrous leadership on the work engagement (WE) of
health professionals. It delves into the potential mechanisms through which ambidextrous
leadership practices could enhance WE among this group. Subsequently, the research seeks to
determine the effects of ambidextrous leadership on less direct variables that influence health
professionals' WE, such as employee ambidexterity and creativity.
The foundation of this inquiry is a thorough review of relevant literature, leading to the
development of a conceptual model. This model is rigorously analyzed using Partial Least Square
– Structural Equation Modeling (PLS-SEM). This approach is particularly relevant in responding
to recent demands for more focused research on ambidextrous leadership within the healthcare
sector. To our knowledge, this investigation represents an initial effort to systematically explore
and quantify the relationship between ambidextrous leadership and high-performance work
systems in health services research. The structure of the paper is methodically organized to
enhance clarity and flow of information. It begins by defining the key concepts and exploring their
interrelationships. Following this foundational work, it presents research hypotheses and illustrates
the conceptual model. The methodology section describes the selected context and details the
empirical analysis conducted. The results are then thoroughly discussed, providing a robust basis
for the subsequent section, which offers recommendations for implementing effective leadership
styles and practices in healthcare settings. These practices aim to optimize the engagement of
health professionals by encouraging them to think and act in ways that foster exceptional
engagement in their roles. It is posited that in complex healthcare environments, leadership that
effectively balances explorative and exploitative strategies might be particularly beneficial,
thereby enhancing overall work engagement among health professionals. The following questions
serve the purpose of given study:
Research Question 1: How does ambidextrous leadership (AL) among healthcare professionals
influence their work engagement (WE)?
Research Question 2: What is the relationship between ambidextrous leadership (AL) among
healthcare professionals and their organizational performance (OP)?
Research Question 3: How does ambidextrous leadership (AL) correlate with the implementation
of high-performance work systems (HPWS) among healthcare professionals?
Research Question 4: To what extent does the relationship between ambidextrous leadership (AL)
and work engagement (WE) among healthcare professionals depend on high performance work
systems (HPWS)?
Research Question 5: Is the impact of ambidextrous leadership (AL) on organizational
performance (OP) among healthcare professionals mediated by high performance work systems
(HPWS)?

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Research Question 6: How does organizational performance (OP) mediate the relationship
between employees' ambidexterity (EA) and their work engagement (WE) among healthcare
professionals?
Thus, these questions highlight the existing problem that in the dynamic and often crisis-laden
environments of healthcare sectors in developing countries, the quality of leadership is pivotal in
navigating operational challenges and enhancing workforce productivity. In Pakistan, healthcare
professionals frequently encounter high-pressure situations, especially in facilities designated as
COVID-19 emergency response centers. This backdrop necessitates an investigation into the
effectiveness of ambidextrous leadership, which embodies the capability to foster both explorative
and exploitative activities among employees. Previous studies have predominantly focused on
developed economies with mature healthcare systems, leaving a significant gap in understanding
how ambidextrous leadership impacts work engagement and organizational performance within
the developing world's healthcare context.
The proposed study aims to fill this gap by empirically examining whether ambidextrous
leadership can enhance work engagement and thereby improve organizational performance among
healthcare professionals in Pakistan. This inquiry is essential, as the outcomes may provide
empirical support for the adoption of ambidextrous leadership practices in healthcare settings
characterized by crisis and pressure, common in developing countries. Given the complex
interplays of leadership styles, employee engagement, and performance outcomes in such settings,
this study seeks to delineate the direct and mediated relationships between these variables, thereby
offering actionable insights for policy-makers and healthcare administrators to optimize leadership
development and strategic human resource interventions.
REVIEW OF THE LITERATURE
The first part of this section describes the concept from Fig. 1, the conceptual model, which is
depicted in the next section. The presentation of individual concepts follows a logic of
relationships, starting from the left side of Fig. 1 (with “leadership practice”) to the right side. The
second part of the section considers the relationships between the different concepts.
Ambidextrous Leadership (AL)
Ambidextrous Leadership refers to the capability of leaders to simultaneously manage and balance
both innovative, risk-taking activities (exploration) and efficient, predictable activities
(exploitation) within an organization to achieve strategic objectives (Gibson & Birkinshaw, 2004).
Ambidextrous leadership is a concept that focuses on the ability of leaders to balance exploitation
of existing resources and exploration of new opportunities within an organization (Raisch &
Birkinshaw, 2008). This balancing act is crucial for organizational success in today's dynamic and
competitive business environment (O'Reilly & Tushman, 2013).
According to Gibson and Birkinshaw (2004), ambidextrous leadership involves simultaneously
exploiting the current knowledge and capabilities of the organization while exploring new ideas
and innovations. Leaders who are able to effectively manage this duality can lead their
organizations to sustainable competitive advantage (Volberda, 2013).
Research by Jansen, Van Den Bosch, and Volberda (2006) suggests that ambidextrous leadership
requires leaders to create a balancing act between structure and flexibility within the organization.
By encouraging experimentation and risk-taking while also maintaining a focus on efficiency and
productivity, leaders can foster an environment that promotes innovation and adaptability (Chen
& Miller, 2012).
Effective ambidextrous leadership has been linked to improved performance outcomes in
organizations (O'Reilly & Tushman, 2011). By promoting a culture of exploration and

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exploitation, leaders can drive organizational growth and success in the long term (Floyd & Lane,
2000).
Thus, ambidextrous leadership is a critical capability for leaders in today's fast-paced and
competitive business environment. By balancing exploitation and exploration, leaders can drive
innovation and growth within their organizations, ultimately leading to sustainable competitive
advantage and also enhanced work engagement and the study addresses the need for further
research and investigation of this style.
High Performance Work Systems (HPWS)
High Performance Work Systems involve a comprehensive set of human resource strategies
designed to enhance employee skills, commitment, and productivity, thereby transforming staff
into a sustainable competitive asset for the organization. These strategies often include extensive
recruitment and selection processes, incentive and compensation schemes, performance
management systems, and substantial employee training and engagement (Boxall & Purcell,
2011).
A high-performance work system has been widely recognized as a strategic approach to managing
human resources that aims to enhance organizational effectiveness and performance. This system
encompasses a set of human resource practices such as employee involvement, skill development,
rewards systems, performance management, and work design that are believed to collectively
promote employee motivation, skills development, and innovative work behaviors (Boxall &
Macky, 2014). Ambidextrous leadership, which involves the ability to balance between
explorative and exploitative behaviors, has gained attention in recent years as a critical leadership
competency for organizations seeking to thrive in dynamic and competitive environments (Jansen
et al., 2016). Research suggests that ambidextrous leadership can facilitate organizational learning,
innovation, and adaptation by encouraging employees to explore new ideas while also exploiting
existing resources and capabilities (Rosing et al., 2011). Work engagement, defined as a positive,
fulfilling, work-related state of mind characterized by vigor, dedication, and absorption, has been
identified as a key driver of individual and organizational performance (Saks, 2006). Engaged
employees are more likely to exert discretionary effort, show higher levels of job satisfaction, and
exhibit lower levels of turnover intentions compared to disengaged employees (Bakker & Bal,
2010). The role of high-performance work systems as a mediator in the relationship between
ambidextrous leadership and work engagement has gained attention in the literature. By
implementing a high-performance work system, organizations can create an environment that
supports ambidextrous leadership behaviors and fosters employee engagement. For example, a
high-performance work system that emphasizes employee involvement and skill development can
enable leaders to empower employees to engage in exploratory activities while also providing the
necessary resources and support to ensure successful outcomes. In conclusion, the integration of
ambidextrous leadership, high-performance work systems, and work engagement can create a
mutually reinforcing system that promotes organizational innovation, agility, and performance.
Future research should continue to explore the mechanisms through which these concepts interact
and influence each other to inform practice and theory in the field of organizational behavior and
human resource management.
Work Engagement (WE)
Work Engagement is characterized as a psychological state related to work that includes three
positive dimensions: vigor, dedication, and absorption. Vigor is the energy that allows an
individual to exert considerable effort at work, overcoming challenges. Dedication refers to the
emotional and cognitive involvement in one’s work, enhancing feelings of significance,

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enthusiasm, and pride in one's profession. Absorption represents a high level of focus and
concentration on work tasks, making it difficult to detach from work and causing time to seem to
pass quickly.
Ambidextrous leadership, which enables leaders to support both explorative and exploitative
activities, is essential in dynamic settings such as healthcare, where adaptability to technological
advancements and patient care practices is critical. Rosing, Frese, and Bausch (2011) highlight
that ambidextrous leadership correlates with increased team innovation and adaptability, while
Zacher and Rosing (2015) note its role in enhancing organizational agility.
High-performance work systems (HPWS), encompassing robust employee recruitment, training,
and retention practices, are linked to improved organizational performance through increased
employee satisfaction and productivity (Becker & Huselid, 2006). In healthcare, where services
are labor-intensive and highly specialized, aligning human resources with organizational goals is
crucial for operational efficiency (Pfeffer, 1998).
Furthermore, work engagement among healthcare professionals significantly impacts patient
outcomes and staff retention. Bakker and Demerouti (2007) argue that work engagement results
from adequate job resources and a supportive environment, which are instrumental in improving
job performance and reducing turnover intentions. Additionally, engaged healthcare professionals
demonstrate higher levels of empathy and patient care, which are vital for patient satisfaction and
treatment adherence (Schaufeli, Bakker, & Salanova, 2006).
Therefore, exploring the interplay between ambidextrous leadership, HPWS, and work
engagement in healthcare is important. Investigating how these factors collectively enhance
healthcare delivery could provide valuable insights into optimal management practices and
improve employee outcomes in this sector.
Organizational Performance (OP)
Organizational Performance is defined as the capacity of an organization to effectively meet its
strategic objectives across various dimensions, including financial outcomes, customer
satisfaction, internal processes, and learning and growth, as outlined by Kaplan and Norton (1992).
Organizational performance is a critical aspect of businesses that encompasses the achievement of
strategic goals and objectives. Researchers have identified various factors that impact
organizational performance, including leadership styles and the adoption of high performance
work systems. This literature review aims to explore the relationship between ambidextrous
leadership, high performance work systems, and organizational performance.
Organizational performance in the healthcare sector can be significantly influenced by
ambidextrous leadership, which refers to the ability of leaders to effectively manage and balance
both explorative and exploitative activities within an organization. This type of leadership is
crucial in healthcare due to the dynamic nature of the industry, which requires continuous
innovation while maintaining efficient daily operations (Christofi, 2024).
Explorative activities in healthcare involve the pursuit of innovative solutions and technologies,
such as new treatments or cutting-edge medical devices, which can lead to substantial
improvements in patient care and healthcare outcomes. Exploitative activities, on the other hand,
focus on optimizing existing resources, processes, and capabilities to enhance operational
efficiency and service quality (Lu et al. 2024).
Ambidextrous leadership supports organizational performance by fostering a culture that values
both types of activities. Leaders who exhibit this style are adept at navigating the complexities of
healthcare management, ensuring that their organizations are not only adaptable and forward-
thinking but also stable and reliable.

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The effectiveness of ambidextrous leadership in the healthcare sector can be assessed through
various metrics such as patient satisfaction, treatment outcomes, operational efficiency, and
innovation rates (Slåtten et al., 2023). Organizations that successfully implement this leadership
style may see improved adaptability in response to environmental changes, better alignment
between innovation and core operational processes, and ultimately, enhanced overall performance.
In summary, ambidextrous leadership is a valuable approach in the healthcare sector, enabling
organizations to thrive by simultaneously exploring new opportunities and optimizing existing
operations. This balance is essential for sustaining long-term organizational health and
effectiveness in a rapidly evolving industry landscape. Ambidextrous leadership refers to the
ability of leaders to balance exploration (innovation) and exploitation (efficiency) within their
organizations. Ayoko et al. (2012) found that ambidextrous leadership positively influences
organizational innovation and performance. Leaders who can effectively manage both exploration
and exploitation are better equipped to adapt to dynamic environments and drive organizational
success.
High performance work systems (HPWS) are a set of human resource practices designed to
enhance employee skills, motivation, and performance. Gong et al. (2013) highlighted the role of
HPWS in enhancing employee commitment, skills, and motivation, leading to improved
organizational performance. HPWS can act as a mediator in the relationship between leadership
styles, such as ambidextrous leadership, and organizational outcomes.
The Social Exchange Theory provides a theoretical framework to understand the relationship
between leadership styles, high performance work systems, and organizational performance.
According to this theory, employees engage in positive exchanges with their organization when
they perceive that their needs are being met through supportive leadership behaviors and
opportunities for skill development provided by HPWS. In conclusion, ambidextrous leadership
and high performance work systems are critical factors that influence organizational performance.
By incorporating HPWS as a mediator in the relationship between ambidextrous leadership and
organizational outcomes, organizations can enhance employee skills, motivation, and
commitment, leading to improved overall performance.
Hypothesis of Study
In the light of all discussion the study developed following hypothesis:
Hypothesis 1 There is a positive relationship between health professionals’ AL and their WE.
Hypothesis 2 There is a positive relationship between health professionals’ AL and their OP
Hypothesis 3 There is a positive relationship between the AL of health professionals and their
HPWS.
Hypothesis 4 The relationship between health professionals’ AL and WE is mediated by HPWS.
Hypothesis 5 The relationship between health professionals’ AL and OP is mediated by HPWS.
Hypothesis 6 The relationship between health professionals’ EA and WE is mediated by OP.
Conceptual model
Figure 1 depicts the conceptual model. All concepts in Fig. 1 are categorized into one of three
categories, labeled (i) “Leadership style,” (ii) “Mediator,” and (iii) “Organizational Outcome
Factors.” The arrow signals the presence of a relationship between each of the three categories.
Specifically, starting from the left in Fig. 1, we assume a logic where leadership practice is
expected to function as a triggering factor that has an impact on the other two (“Employees’
activities” and “Job-directed performance”). In line with the aim and focus of this study, AL
represents the category “Leadership style.” HPWS represents the category “Mediator.” WE and
OP represent the category “Outcome Factors.” The solid line in Fig. 1 visualizes the assumption

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about direct relationships, while broken lines visualize the assumption about indirect relationships.
Figure1.

Methodology
Sample and procedure
Ambidextrous leadership is pivotal in fostering organizational adaptability and success within
dynamic environments (Rosing, Frese, & Bausch, 2011). The healthcare sector, requiring a balance
between innovative patient care and cost-effective administrative practices, presents a context
where such leadership could yield significant benefits (Zehir & Zehir, 2023). This study aims to
explore how ambidextrous leadership impacts strategic human resource practices and
subsequently, organizational outcomes where HPWS refer to a group of human resource practices
designed to enhance employee skills, commitment, and productivity (Combs, Liu, Hall, &
Ketchen, 2006). In healthcare, these systems may encompass extensive training, empowerment
initiatives, and performance incentives. This study will examine the mediating role of HPWS in
facilitating the effects of ambidextrous leadership on organizational outcomes, positing that HPWS
may effectively channel leadership influences to enhance both employee engagement and
organizational performance (Khan, 2024). The effectiveness of ambidextrous leadership and
HPWS is ultimately reflected in improved organizational performance and elevated work
engagement among healthcare workers. Organizational performance in this context includes
metrics such as patient care quality, operational efficiency, and financial outcomes. Work
engagement is considered through the lens of psychological states of healthcare employees,
including aspects of vigor, dedication, and absorption in work (Schaufeli, Bakker, & Salanova,
2006). This investigation aims to provide a comprehensive understanding of how leadership and
HR strategies impact the healthcare sector. The research study is aimed to explicate the pathways
through which ambidextrous leadership affects organizational performance and work engagement
in the healthcare sector, focusing on the mediating role of HPWS. This study aims to contribute to
the expansion of theoretical frameworks concerning leadership and organizational behavior and
provide practical insights for healthcare management.
Approximately 17 hospitals were invited to participate in the study. Out of the 17, nine willingly
agreed to participate in the research, an acceptance rate of approximately 53%. The focus of
investigation in this study was the healthcare professionals employed in various hospitals across
Pakistan. The data collection for this study will be undertaken in major metropolitan centers,
namely Islamabad, Lahore, and Karachi. The establishment of appropriate inclusion criteria for
healthcare workers is crucial for any study. Given study has following criteria deployed for further

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analysis and explanations. Healthcare workers with a minimum organizational tenure, such as one
year, to ensure that they are sufficiently familiar with leadership and organizational systems (Judge
& Piccolo, 2004). A range of healthcare roles, including doctors, nurses, and administrative
personnel, should be considered to capture a comprehensive perspective of the organization
(Eisenbeiss et al., 2008). Workers from diverse regions within Pakistan were included to control
for potential geographic variations in leadership styles or organizational performance (Uhl-Bien
& Marion, 2009). Healthcare organizations of different sizes were part of the study to assess the
impact of organizational size on the leadership-performance relationship (Hair et al., 1998) with
full-time job were included to ensure a stable degree of interaction with organizational leadership
styles (Podsakoff et al., 1996) from government and private hospitals. Hospitals that had
established performance metrics to facilitate the assessment of organizational performance
(Fornell & Larcker, 1981). Obtaining informed consent from healthcare workers willing to engage
in data collection methods such as surveys or interviews was imperative (Hair et al., 1998).
The survey was distributed to about 500 employees, yielding 258 completed questionnaires, a
response rate of 51.6%. The personal characteristics of the participants of this study are presented
in Table 1.

Table 1: Personal characteristics of the study sample (N = 258)

Category Details %
Staff role Doctors 34.5
Nurses 49.2
Other (health professionals) 16.3
Employed < 5 years 35.7
6–15 years 26.7
16–25 years 23.3
> 25 years 14.3
Sector Private 66.7
Government 33.3
Age < 35 years 27.5
35–50 years 38.4
> 50 years 34.1

Instrumentation
Claims in each main measure (AL, EA, SQC, and C) were adopted. Each measure included claims
with the seven-point Likert scale, ranging from “strongly disagree” (1) to “strongly agree” (7). In
addition, the survey included a section on demographic characteristics, as summarized in Table 1.
The data will be collected through self-administered questionnaires using an online survey
platform. AL was adapted and measured through an 11-item scale from Roosing et al., 2011.
Organizational Performance will be measured using scale of Kaplan & Norton, 1992, p. 72). High-
Performance Work Systems was measured using a scale developed by Huselid (1995). Work
Engagement Scale was derived from the University of Utrecht job Engagement Scale (UWES) by
Schaufeli and Bakker in 2003. Organizational Performance was measured using scale of Kaplan
& Norton, 1992, p. 72).
Data analysis

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Given study employed partial least squares structural equation modeling (PLS-SEM) (Hair et al.,
2022) as the data analytical procedure to test the hypotheses in given conceptual model using the
SmartPLS 3 software (Ringle et al., 2015) . PLS-SEM was selected to evaluate the conceptual
model because it is effective for explaining the variance in the model's dependent variables such
as HPWS, WA, and OP, as detailed by Hair et al. (2022). SmartPLS is the predominant software
for variance-based analyses within PLS-SEM. This software conducts the analysis through a two-
stage process. Initially, it assesses the reliability and validity of the measurement model's
item/claim measures. Subsequently, the focus shifts to evaluating the structural model's path
coefficients. The mediator effects were also quantified and assessed using the bootstrapping
method as per Zhao et al. (2010). The findings of this research align with previous literature,
including Hair et al. (2019), on the reporting of PLS-SEM data.
FINDINGS AND INTERPRETATION
Measurement model
As the measurement models contained only reflective constructs, the assessment was based on
primarily, convergent validity (the extent to which a variable is positively correlated with
alternative variables used to measure the same construct, i.e. loading and average variance
extracted); then internal consistency reliability (the magnitudes of the intercorrelations of the
observed variables, using the criterion’s composite reliability and Cronbach’s alpha); and lastly
discriminant validity (the extent to which a construct is distinct from other constructs, using the
heterotrait– monotrait ratio criterion). The given study used the ‘rule of thumb’ criteria (Hair et al.
2015). The results in Table 3 indicated there exists reliable and valid measurement models.
Table 3 Results of the measurement model for the AL, HPWS, WE and OP constructs * AVE =
Average variance extracted; HTMT = Heterotrait–monotrait ratio of correlations

Structural model
The results for the structural model are presented in Fig. 2.
Figure2.

Fig. 2 Direct and indirect effect results from the structural model of the links between AL, HPWS, WE and OP.

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Construct Claims Claims

label
In general, my leader:
AL AL1 Allows different ways of accomplishing tasks.
AL2 Encourages experimentation with different ideas.
AL3 Gives possibilities for independent thinking and acting.
AL4 Gives room for other colleagues’ own ideas.
AL5 Allows errors.
AL6 Encourages error learning.
AL7 Monitors and controls goal attainment.
AL8 Establishes routines.
AL9 Takes corrective action, if necessary.
AL10 Controls adherence to rules.
AL11 Sticks to plans.
In general, here:
HPWS HPWS1 Employees are involved in job rotation.
HPWS2 Employees are empowered to make decisions.
HPWS3 Jobs are designed according to employee skills and capabilities.
HPWS4 Selection is comprehensive (uses interviews, tests etc.)
HPWS5 Selection emphasizes their ability to join forces and work in teams.
HPWS6 Selection involves selecting the best candidate, regardless of the
specific job.
HPWS7 Selection emphasizes promotion
HPWS8 Selection places main concern on their potential to learn (e.g.,
aptitude).
HPWS9 Training is on regular basis.
HPWS10 Training programs are comprehensive.
HPWS11 Training programs are to develop field-specific skills and
knowledge.
HPWS12 The training programs emphasize on-the-job experiences.
HPWS13 Performance is based on objective, quantifiable results.
HPWS14 Performance appraisals include feedback.
HPWS15 Incentives are based on team performance.
HPWS16 Compensation packages include an extensive benefits package.
HPWS17 compensations include high wages.
HPWS18 The incentive system is associated to skill-based pay.
HPWS19 compensation is related to performance.
To which extent do you agree or disagree with these claims?
WE WE1 At my workplace, I experience a high level of energy.
WE2 I take pride in the professional tasks I accomplish.
WE3 I find myself deeply engaged in my work tasks.
WE4 During work, I occasionally find myself intensely involved to the
point of losing track of time.
WE5 In my professional role, I sense robustness and vitality and I
experience contentment during periods of intense work.

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Journal of Tourism, Hospitality, and Services Industries Research (JTHS) Volume 4, No.1, June 2024

WE6 I hold a positive attitude toward my work responsibilities.

WE7 My occupational duties elicit inspiration in me.
WE8 Upon waking up, I have the inclination to proceed with my work
activities.
To which extent do you agree or disagree with these claims?
OP OP1 The organization focuses on quality of Services
OP2 The organization encourages the development of new ways of
treatment, diagnosis and services
OP3 The organization provides attraction to employees
OP4 The organization can retain employees
OP5 Organization focuses on patient satisfaction
OP6 Organization emphasis on healthy relationships between senior
management and employees
TABLE 3

Convergen Internal consistency Discriminant

t validity reliability Validity
Constru Claims Indicator Composi Cronbach’ HTMT criterion*
ct label reliability te s alpha
reliabilit
y
‘Rule of Loading > 0.7–0.95 0.7–
thumb’ 0.7 0.95
AL AL1 0.80 0.60 0.94 0.9 Yes
3
AL2 0.85
AL3 0.72
AL4 0.87
AL5 0.70
AL6 0.81
AL7 0.66
AL8 0.80
AL9 0.83
AL10 0.75
AL11 0.70
HPWS HPWS 1 0.79 0.70 0.93 0.9 Yes
1
HPWS 2 0.82
HPWS 3 0.83
HPWS 4 0.90
HPWS 5 0.85
HPWS 6 0.82
HPWS6 0.79
HPWS7 0.82
HPWS8 0.83

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Journal of Tourism, Hospitality, and Services Industries Research (JTHS) Volume 4, No.1, June 2024

HPWS9 0.90
HPWS10 0.85
HPWS11 0.82
HPWS12 0.79
HPWS13 0.82
HPWS14 0.83
HPWS15 0.90
HPWS16 0.85
HPWS17 0.82
HPWS18 0.79
HPWS19 0.82
WE WE 1 0.83 0.72 0.88 0.8 Yes
0
WE 2 0.91
WE 3 0.80
WE 4 0.83
WE 5 0.91
WE 6 0.80
WE 7 0.83
WE 8 0.91
OP OP1 0.96 0.94 0.95 0.9 Yes
3
OP 2 0.97
OP 3 0.95
OP 4 0.96
OP 5 0.91
OP 6 0.95

Standardized coefficients (*** < 0.01, ** < 0.05, * < 0.10). Note that the reported path parameters
on the dotted lines are indirect effects while the direct effect are shown in parentheses. The research
study tested the intra-construct correlations of the latent variables, namely AL, OP, WE, and
HPWS, and found no issues as depicted in Table 4.
Table 4 Intra-construct (latent variables) correlations
AL HPWS WE OP
Ambidextrous leadership (AL) 1.000
High Performance Work Systems 0.256 1.000
(HPWS)
Work Engagement (WE) 0.395 0.413 1.000
Organizational Performance (OP) 0.372 0.401 0.372 1.000

The R^2 values for the endogenous constructs in the model were 0.16 for HPWS, 0.26 for WE,
and 0.18 for OP. These values are deemed reasonable based on the benchmarks established by
Hair et al. (2015). The analysis revealed that health professionals' AL significantly influenced their
WE, thereby supporting hypothesis 1. Specifically, the path coefficient for the relationship
between AL and WE was β=0.24, with a p-value of 0.010. Although hypothesis 2 indicated a

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positive path coefficient of β=0.11 for the relationship between AL and OP, it was not statistically
significant (p-value=0.111). Conversely, hypothesis 3, which proposed a relationship between AL
and HPWS, showed a significant positive path coefficient of β=0.40 (p-value=0.000).
Further analysis on mediation hypotheses 4, 5, and 6 indicated support for these hypotheses.
Specifically, hypothesis 4 suggested that HPWS mediates the relationship between AL and WE,
with a path coefficient of β=0.07 (p-value=0.048) (Slåtten et al., 2023). Hypothesis 5 posited that
HPWS mediates the relationship between AL and OP, resulting in a path coefficient of β=0.15 (p-
value=0.002). Lastly, hypothesis 6 proposed that OP mediates the relationship between HPWS and
WE, showing a path coefficient of β=0.10 (p-value=0.003). These results demonstrate that HPWS
mediates the relationships between AL and both WE and OP (hypotheses 4 and 5), and the
relationship between HPWS and WE is mediated by OP (hypothesis 6). In summary, the study
identified partial mediation in the relationships posited in hypotheses 4 and 6 and full mediation
in the relationship proposed in hypothesis 5.
Discussion and Conclusion
The application of ambidextrous leadership in the healthcare sector, as discussed in the context of
post-pandemic workplace requirements, becomes particularly useful and vital. The healthcare
industry, characterized by its dynamic and high-stakes environment, demands a leadership
approach that can adapt to rapid changes while maintaining high standards of care and operational
efficiency. Implementing this leadership style in healthcare encourages professionals to adapt to
new technologies and methods without the fear of making mistakes, fostering an innovative culture
that can lead to breakthroughs in patient care and health management. For example, exploration
can drive the adoption of telemedicine, personalized medicine, and AI-driven diagnostics, while
exploitation ensures that these innovations are implemented effectively and contribute to improved
patient outcomes.
Human Resource Development (HRD) professionals in healthcare must therefore focus on
cultivating leaders who can manage both aspects of ambidextrous leadership. This involves
training and development programs that emphasize agile thinking and resilience, preparing leaders
to handle both the routine and the revolutionary with equal proficiency. In sum, the strategic role
of ambidextrous leadership in the healthcare sector not only enhances employee engagement
through a high performance and supportive work environment but also directly contributes to the
sector's ability to respond to evolving health crises and improve patient care outcomes.
This study uncovered the role played by AL and HPWS for health professionals’ value creation
manifested in their job-directed performance (referring to WE and OPC) as frontline employees.
The study makes three contributions. First, it conceptualizes AL as a leadership style and practice
of health professionals and contributes to understanding how AL is linked to and affects work
engagement of healthcare professionals. Second, it proposes HPWS as a type of employee activity
that AL affects. Moreover, the important role of HPWS in promoting health professionals’ WE
and OP is also revealed. Third, the study reveals how and in what way health professionals’ HPWS
and OP can strengthen health professionals’ WE offerings. This is, to the authors’ knowledge, the
very first study to both conceptualize and empirically test AL and EHPWS as factors developing
the WE and OP of health professionals. The study responds to the call for research on the concept
of AL (Gouda & Tiwari, 2024) in health-care research. Consequently, this study investigated the
impact of ambidextrous leadership (AL) on work engagement (WE) and organizational
performance (OP) in the healthcare sector, with high-performance work systems (HPWS) posited
as a mediating factor. The results provide a nuanced understanding of how leadership styles
influence both employee engagement and performance outcomes in healthcare settings.

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The in-sample predictive power of the model, indicated by R^2 values of 0.16 for HPWS, 0.26 for
WE, and 0.18 for OP, suggests a reasonable level of explanatory power according to the standards
by Hair et al. (2015). These findings underscore the relevance of the selected constructs in the
healthcare context, reflecting their substantial role in the dynamics of organizational performance.
The analysis strongly supported Hypothesis 1, showing a significant positive relationship between
ambidextrous leadership and work engagement, as evidenced by a path coefficient of β=0.24 (p-
value=0.010). This suggests that the ability of healthcare leaders to balance explorative and
exploitative behaviors positively impacts employee engagement levels. Hypothesis 2, which
posited a positive relationship between AL and OP, however, did not reach statistical significance,
with a path coefficient of β=0.11 and a p-value of 0.111. This indicates that while AL may
influence OP, other factors not accounted for in this model might be at play or the direct impact of
AL on OP is weaker than anticipated. The results for Hypothesis 3, which showed a robust positive
relationship between AL and HPWS (β=0.40, p-value=0.000), demonstrate that ambidextrous
leadership is a potent influencer of the adoption or enhancement of high-performance work
systems. This finding highlights the role of versatile leadership in fostering environments that
enhance both the capabilities and the performance of healthcare organizations.
Furthermore, the mediation analyses (Hypotheses 4, 5, and 6) revealed intricate dynamics. HPWS
was found to mediate the relationship between AL and both WE and OP (Hypotheses 4 and 5).
Specifically, the path coefficients of β=0.07 (p-value=0.048) for the mediation of AL and WE, and
β=0.15 (p-value=0.002) for the mediation of AL and OP, suggest that the implementation of high-
performance practices can enhance the impact of ambidextrous leadership on both employee
engagement and organizational performance. The mediation of HPWS between AL and WE is
particularly compelling, indicating that HPWS not only supports, but actively enhances, the
relationship between leadership style and employee engagement.
Hypothesis 6 posited that OP mediates the relationship between HPWS and WE, with a significant
path coefficient of β=0.10 (p-value=0.003). This supports the notion that organizational
performance can be a crucial link between effective work systems and enhanced employee
engagement, highlighting a reciprocal benefit between operational success and workforce
motivation.
In summary, the study underscores the significance of ambidextrous leadership in developing high-
performance work systems and enhancing work engagement and organizational performance in
the healthcare sector. These findings suggest that healthcare organizations might benefit from
fostering leadership styles that are flexible and adaptable, promoting both innovative and
optimized practices that enhance both immediate and strategic outcomes.
This paper contributes in building a piece of knowledge regarding AL and HPWS, which is a
domain that has been neglected in previous health services research. Specifically, the findings
reveal how AL and HPWS can promote health professionals’ WE and OP. The study implies that
health-care organizations must be determined to employ, train, and expand their leaders to become
AL. Doing so will have a direct impact on WE as well as HPWS. In addition, AL will also
transform HPWS in a positive direction and indirectly stimulate employees’ OP as well as
strengthen health professionals’ WE offerings. Furthermore, the findings of this study suggest
several policy implications for the healthcare sector. First, healthcare organizations should
consider adopting ambidextrous leadership (AL) as a formal part of their leadership development
programs. Given the significant positive relationship between AL and work engagement, and the
indirect benefits on organizational performance through high-performance work systems (HPWS),
policies that promote such leadership styles could enhance both employee satisfaction and

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Journal of Tourism, Hospitality, and Services Industries Research (JTHS) Volume 4, No.1, June 2024

healthcare delivery. Training programs that focus on developing the skills necessary for both
exploitation (optimizing current systems and procedures) and exploration (innovating and adapting
to new challenges) should be prioritized.
Secondly, policy makers should encourage the implementation of HPWS in healthcare settings.
This study’s findings underscore the mediating role of HPWS in enhancing the effects of AL on
both employee engagement and organizational performance. As such, policies that support the
development of these systems could further strengthen the sector's resilience and adaptability,
particularly in post-pandemic scenarios where these qualities are crucial. Lastly, considering the
role of AL in fostering an environment that promotes the adoption of technological advancements
such as AI and telemedicine, healthcare policies should also support the integration of these
technologies into routine healthcare practices. This could include funding for technology adoption,
incentives for organizations that demonstrate innovative practices, and regulations that facilitate
safe and efficient technology use in healthcare.
Limitations of the Study
While this study provides valuable insights, several limitations must be acknowledged. The study's
predictive power, as indicated by the R^2 values, while reasonable, suggests that there are other
variables not captured by this model that may influence HPWS, work engagement (WE), and
organizational performance (OP). Further research could explore additional factors that might
impact these relationships.
Additionally, the non-significant relationship between AL and OP directly, as indicated by the p-
value associated with this relationship, suggests a more complex dynamic that may involve other
mediating or moderating variables not considered in this study. Future studies could aim to uncover
these variables to provide a more comprehensive understanding of how AL impacts OP.
Moreover, the study's focus on a single sector (healthcare) and the potential for regional biases due
to the study's geographical limitations suggest that the findings may not be universally applicable
to other sectors or regions. Replication of this study in other contexts, both within and outside the
healthcare sector, would be beneficial to confirm the applicability of the findings.
In conclusion, while this study advances our understanding of ambidextrous leadership and high-
performance work systems in healthcare, acknowledging and addressing its limitations through
continued research will be crucial for developing more effective leadership practices and policies.
Future Research Directions
To further explore ambidextrous leadership (AL) and high-performance work systems (HPWS) in
healthcare and other sectors, future studies could consider the following approaches: Longitudinal
Studies: Implement longitudinal designs to track changes in work engagement, organizational
performance, and HPWS over time, offering insights into causal relationships and long-term
effects. Diverse Settings: Conduct research in various geographical locations and healthcare
environments to test the generalizability of the findings across different institutional and cultural
contexts. Additional Variables: Include variables such as organizational culture, employee
autonomy, and external factors like regulatory changes to better understand their impact on AL,
HPWS, and organizational outcomes. Qualitative and Mixed-Methods Approaches: Use
qualitative methods such as interviews and case studies to gain deeper insights into how AL and
HPWS are perceived and implemented by healthcare professionals. Mediating and Moderating
Variables: Explore potential mediators and moderators, such as employee well-being or
technology adoption, to uncover additional pathways and conditions affecting the effectiveness of
AL and HPWS. Sector-Wide Comparative Studies: Compare the impact of AL and HPWS across
different sectors to determine their applicability and effectiveness in various organizational

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contexts. Impact of Training Programs: Evaluate the effectiveness of training programs designed
to develop ambidextrous leadership skills, particularly their influence on leaders’ ability to balance
exploitation and exploration.

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