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ORIGINAL RESEARCH
published: 10 February 2022
doi: 10.3389/fpubh.2021.778101
Frontiers in Public Health | www.frontiersin.org 1February 2022 | Volume 9 | Article 778101
Edited by:
Wen-Yi Chen,
National Taichung University of
Science and Technology, Taiwan
Reviewed by:
Mariela Deliverska,
Medical University Sofia, Bulgaria
Afzal Ahmed Dar,
Shaanxi University of Science and
Technology, China
*Correspondence:
Yaoping Liu
yaoping.l@mail.rmutk.ac.th
Specialty section:
This article was submitted to
Health Economics,
a section of the journal
Frontiers in Public Health
Received: 16 September 2021
Accepted: 16 December 2021
Published: 10 February 2022
Citation:
Liu W and Liu Y (2022) The Impact of
Incentives on Job Performance,
Business Cycle, and Population
Health in Emerging Economies.
Front. Public Health 9:778101.
doi: 10.3389/fpubh.2021.778101
The Impact of Incentives on Job
Performance, Business Cycle, and
Population Health in Emerging
Economies
Wei Liu 1and Yaoping Liu 2
*
1Department of Business Administration, International College, Rajamangala University of Technology Krungthep, Bangkok,
Thailand, 2Department of Global Buddhism, Institute of Science Innovation and Culture, Rajamangala University of
Technology Krungthep, Bangkok, Thailand
In the past, different researchers have conducted studies on incentives and how they are
linked to employee motivation, influencing emerging economies. This study addresses
two gaps as outlined in previous studies. One research gap exists in examining employee
loyalty and employee engagement in relation to the business cycle. The other gap
is observed in the recommendation that future researchers use different moderators
between incentives, the health of employees, and job performance with population
health. This focus was explored in the present study by identifying the responses of
hospitals and physicians to the business cycle to examine the impact of incentives on job
performance and health of workers in public and private sector hospitals in Shandong,
Eastern China. Data were collected in the form of questionnaires that consisted of
close-ended questions. These questionnaires were then filled out by 171 doctors and
149 nurses working in both public and private sectors in Shandong, Eastern China.
The results showed that there is a relation between different variables. Some variables
have more impact on other variables such as transformational leadership, which has
a significant impact on the job performance and business cycle, whereas monetary
incentives also impact job performance and population health, but this impact was lower
than that of transformational leadership in terms of how job performance influences
emerging economies.
Keywords: employee incentives, job performance, service quality, patient satisfaction, business cycle, population
health, health performance, economies
INTRODUCTION
The population of China is continuously increasing day by day. In 2019 it was 1.4 billion and
is growing at a rate of 0.43% (1). With this population growth, there is a need to focus on the
health facilities that are being provided to people and the employees and workers of the health
sector. Public sector hospitals are trying their best to provide the best facilities to citizens and their
employees but they are lacking in resources compared to the private sector, particularly in terms of
technology and staff (2–4).
Through this comparison of both public and private sector hospitals, we can also see the reasons
why researchers believe that the public sector has low productivity. These include unfriendly and
unprofessional care and an absence of performance based incentives (5,6). This might be linked
to how hospital staff feel about their own health and organization. The present study explores
Liu and Liu Incentives on Job Performance, Business Cycle, and Population Health
employees’ general health and the loyalty of employees regarding
the hospital sector (7). This will help the government sector to
adopt some techniques that are being used in the private sector
and create a working environment that is more conducive to the
health of employees, enabling them to be more productive.
Organizations are trying to adapt according to the changes in
the environment such as those caused by the Covid-19 pandemic
(8). For that purpose, they are focusing on a resource-based
view. They are trying to get a competitive advantage by creating
human capital that is valuable, rare, and difficult to replace. In
doing so, they are making sure that the employees’ needs, i.e.
health, a healthy environment, and incentives are being fulfilled
(9). Organizations believe that fulfilling these needs will lead to
employee loyalty and later on affect their general health and job
performance. Leaders also play a role in creating an environment
that promotes the good health of employees and loyalty of
employees leading toward job performance (10,11). Therefore,
this study focuses on exploring whether incentives are the reason
for the increase or decrease in an employee’s general health and
loyalty. It also tries to evaluate the impact that incentives have
on job performance and the health of workers. This study also
explored the role of leaders in creating employee loyalty and in
job performance (1,12). This study also explores the impact that
leaders have on incentives, and how personal care can affect job
performance.
Employees are assets of an organization and influence
sustainability in organizations. Organizations use various
strategies to retain employees and for that purpose, they have
different policies in the organization that recognize the efforts
of those employees (13,14). They provide them with rewards or
incentives so they may live a healthy life that enables them to
contribure to the organization in positive ways. These incentives
are there in order to make employees motivated and increase
productivity. The rewards system is one beneficial policy for
employees, encouraging them to improve and maintain their
general health and job performance (15).
Different researchers have examined motivational incentive
and reward systems for employees. Some researchers believe
that these incentives are the reason employees feel energetic
and motivated toward their work. However, some researchers
have also focused on the effect that a positive environment
has on employees. If organizations provide them with this
environment, then employees help them in achieving their
goals. When an organization is developing, they try to motivate
employees by training or providing them with different facilities
including healthcare (14,16–19). Thus they utilize the skills of
employees in different ways. A number of past studies have
focused either on the incentive perspective or the environment
and how these are linked to determining job performance.
Environmental factors are important when it comes to job
satisfaction as most employees are satisfied if they have more
developmental opportunities rather than extrinsic rewards (20–
22). If they get the best out of the prevailing conditions, for
example staying healthy during Covid-19, they will certainly do
their best (3,4,23).
In the changing environment, organizations are trying to
adapt. They need to understand the importance of both working
environments and extrinsic rewards (24,25). If one of them
is missing, then employees will not be satisfied with their
work and that dissatisfaction will lead to bad health and
an increase in turnover. Therefore, this research focuses on
both perspectives side-by-side, exploring incentives and the
environment in relation to leadership as these determine general
health, employee loyalty, and the job performance of employees
within an organization (12,21,26).
This research was conducted in public and private hospitals
in Shandong Province, Eastern China. This research will help
in determining employees’ perspectives regarding incentives and
leadership and how they affect their health and loyalty toward
the hospital as well as their performance. This research will help
different HR managers working in the hospital sector and in
other sectors to understand that it is important to focus on both
these perspectives and what things are needed to focus more
on job performance, better health, and how these are linked to
organizational failure or success (27–29). This research furthers
understanding of employee perception and weightage and how
they influence incentives and leadership in the workplace.
This research is based on knowledge gaps identified in two
previously published articles. The first article examined “The
effects of organizational culture and leadership style on employee
engagement and what their impact on employee loyalty is.” In
that article, the researcher recommended that future researchers
further explore different perspectives of employee loyalty and
employee engagement, whether it is in an organizational or an
individual context. They also outline that different factors need
to be encouraged that lead to employee engagement, such as
the leadership styles, as employee engagement has a positive
correlation with employee loyalty. They also mentioned that
future researchers can use different moderating variables in
research. The second article was on “Employee participation,
performance metrics, and job performance: A survey study based
on self-determination theory” (30–32) published in 2017. This
article recommended that future researchers concentrate on the
different moderators that may explain the different relationships
between incentives, general health, and performance (29,33–
35). They also recommend that future researchers provide an
overview of different tasks or their environment as moderators.
LITERATURE REVIEW
Concepts and Definitions
Incentives
Incentives are defined as concrete incentives or any kind of
compensation that is given to an employee in the form of cash.
Incentives can also be defined as the objective criteria where
an individual simply wants to establish quantifiable standards
for performance. Some researchers have divided incentives
into two types, namely concrete and moral incentives. Moral
incentives refer to indirect compensation through certification,
for example appraising someone (36). Concrete incentives refer
to a direct way of compensating one’s effort by giving a bonus.
In this research, we will be talking about the concrete incentives
that are being given to workers. According to the American
Compensation Association, compensation is defined as the
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Liu and Liu Incentives on Job Performance, Business Cycle, and Population Health
cash and non-cash remuneration provided by an employer in
exchange for the services that are provided by the employee (37).
This research discusses concrete or cash remuneration.
A compensation package is when an incentive is used as a
strategic tool to compensate an employee for their performance
and retain them by achieving employee satisfaction and
improving their health for achieving the best job performance
at the same time. Some researchers believe that incentives are
used by employers to trigger and influence the motivation of
employees (38). When they motivate employees, it leads to
improvements in general health, skill and they will also be
satisfied with their work. Most organizations perceive incentives
as a way of achieving their goals (30,36,39). Some researchers
have outlined that compensation was an important factor in
providing health allowances, job satisfaction, and employee
empowerment are also considered to be important factors in
cases of employee loyalty (28,30,39–41).
Some previous research found that the alignment of the
reward system must follow the organization’s design, otherwise,
they send mixed messages (42). Let us take an example of an
automobile company, which designs distinct working activities
as project assignments for the workforce in departments. The
main objectives are that employee pay must be analyzed by
the respective managers of departments and decided with a
finance manager. Consequently, workers will be satisfied and
motivated to meet their functional goals. Although, all the
departments must communicate and work cross-functionally.
Everyone is responsible and accountable for the responsibilities
for which they were hired. The direct supervisor is linked with the
incentives that are being provided to the employees rather than
a person who has no knowledge of the work performed by the
employee. In this way, the employee is motivated and puts effort
into working efficiently to gain rewards (43). Therefore, choosing
a leader who will measure the performance of the employees is
also important.
The reward in satisfying the needs of employees, for example,
the healthcare of their family, as stated by Victor H. Vroom
under the theory of expectancy (44). Incentives were considered
as a form of payment that is directly linked to the performance
of employees. The more profits or incentives the better the
performance of employees. This system of providing monetary
incentives to employees is another way of compensating them
other than their salaries. This system of compensating employees
is based on performance (35,37,45,46). Different research also
shows that employees nowadays are much more motivated by
extrinsic rewards. If they have a greater sense of entitlement,
then they want to work hard to achieve goals. Employees are
not motivated by intrinsic rewards and are more sensitive about
monetary compensation for the work that they do (39,40,44,47).
Employee Loyalty
Employee loyalty is defined as the commitment or psychological
attachment of employees toward the organization. Employee
loyalty is also defined as the capability of the employee to stay
in an organization. It might also depend on how much time they
have spent in an organization and what type of work they do in
an organization (46,48,49).
In the past, employee loyalty was defined as the time
an employee remains in an organization but due to the
environmental changes during the pandemic, its definition was
updated to the time an employee remains committed toward
the organization and is said to be loyal. Previously, employee
loyalty consisted of two major divisions: firstly, loyalty is in
the employer’s best interest; and secondly, loyalty is when an
employee remains with the same employer (50). Employee loyalty
has evolved. Traditionally, it was known as a trust and bond
relationship between employee and employer, which means the
longer the time an employee spends on their job the more loyal
they will be but in recent times leaders do not equate longevity
with loyalty, rather they define loyalty as the commitment
and dedication that an employee gives it to their organization
(51,52). Employee loyalty is considered to be linked with the
survival and success of any organization and if the employers
recognize the importance of an individual, then it means that
they will try to ensure that the employee remains loyal to that
organization (53–55).
Some researchers believe that employee loyalty leads to job
satisfaction. If the employee’s expectations are met, then their
level of satisfaction also increases. This loyalty will develop into
a generalized emotional attitude toward that organization for
which the employee is working (56–59). The more satisfied they
are the more healthy their life, and the more loyal they will
be toward that organization. When employees develop affection
toward their organization, they show loyal behavior by improving
productivity and that helps them in achieving organizational
goals i.e. they provide a better quality of services to employees
whereas, some researchers have mentioned that employee loyalty
is generated due to the presence of job satisfaction (57,58,60,
61). Job satisfaction and the general health of employees are
important variables when it comes to employee loyalty. The
positive or negative feelings of employees might later determine
employee loyalty and eventually affect their performance. When
employees have satisfaction they become committed to that
organization (8,23–25,62) and will remain loyal. A study
showed that if the banking sector continued to provide proper
compensation, training, and appraisals then the employees will
remain committed to the organization and the chances of
turnover will also be less. In the past, different studies have found
out that different employee loyalty behaviors were linked with
how much employees were satisfied with their job, which lead to
a commitment to the job (63). Job security was also one of the
reasons employee loyalty is generated in some individuals (64).
Past research has outlined that employee loyalty has nothing to
do with the human resource management policies and practices,
environmental conditions such as a healthy atmosphere. How
much an employee is satisfied with their job will later determine
the employee loyalty that they develop (65–67). Employee
satisfaction is quite important when an employee is from services
or sales departments as if these employees are not satisfied with
their job then customers are not satisfied with the services they
are providing, which will affect the company’s goals and impact
loyalty toward the organization (64). In this case, employee
satisfaction leads to them being loyal toward the organization.
If they are not healthy and satisfied with their work not only
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do they fail to develop employee loyalty, it will harm the
organization’s performance as well (68,69). Thus, job satisfaction
influences employee loyalty, and later on impacts organizational
commitment as well.
Leadership can be defined by the behaviors employees possess
and how they process their decision-making. A leader is one or
more people who either select, train, or influence their employees.
They have a diverse set of abilities, skills, and knowledge
that helps them to align employee goals with organizational
goals. A leader is a person who influences the behaviors of
employees or their followers (70,71). A leader is also defined
as a person who has the ability to understand and work within
a culture, which makes a leader effective. Leadership style is
defined by the psychological latitude and the behavior they
possess during interaction with employees or while they are
handling their operations or activities (72,73). In this research,
we examine transformational leaders in order to explain the
leadership style used in organizations. Transformational leaders
are defined as those who motivate their followers to achieve
goals through inspirational motivation, intellectual stimulation,
idealized influence, and individual consideration (70,71,74).
They help the followers perform better than expected. They
possess good visioning and use their skills to develop a strong
bond with followers. Transformational leadership is used to
describe the situation where leaders and followers help each other
reach higher levels of morality and motivation (75–79).
Past research has focused on the leadership personality
traits that made people successful leaders but some researchers
believe that leaders have some innate qualities that distinguish
them from other people. Research has started to focus on
the different behavioral aspects of leader’s personality and the
different contingency theories that support situational leadership
outline that leader effectiveness depends upon situational factors
(75). Other researchers have defined leaders based on two
types, including effective leaders and transformational leaders.
Transformational leadership is when leaders motivate their
employees to increase or strengthen their perceptions, behaviors,
commitment, motivation, and beliefs to stay aligned with
organizational goals. Whereas, an effective leader is someone who
influences followers in such a way that leads to an organizational
vision that sets an example by performing a job in such a way
that inspires the followers. In other words, an effective leader is
someone who leads through their actions (11,20,80).
Different leadership styles are seen to be highly supportive
and engage employees in their decision making. This engagement
in different activities of work makes employees happy that
their decision and participation are valued in the organization,
which makes them more loyal (81). Different research has
shown that employee engagement leads to organizational
success (7). Therefore, leader communication strategies have
a significant impact on employee general health and their
loyalty or commitment ultimately affects job performance in an
organization (82). Today, worker loyalty is one of the utmost
factors in the success of an organization. For this reason, key
leader communication strategies are taken into account in the
present study to determine how a worker’s motivation loyalty
can be increased through different leadership communication
strategies, which results in an increase in job and organizational
performance (13).
Job Performance
Job performance is defined as a certain behavior that
organizations expect an individual to carry out. Different
researchers have defined job performance as a multidimensional
concept that includes both task performance as well as
contextual performance (81). Task performance is defined as
an employee’s contribution toward the organization i.e., their
technical competencies and job proficiency, whereas contextual
performance is not linked with the formal job requirements of
an employee (32). This article focuses on the task performance
of the employee. Here, performance includes the outcomes of a
particular job that an employee is performing at their workplace.
Thus, it is more linked with the task performance of an employee.
It is also linked with the employees’ behavior toward their work.
Performance is composed of many other different concepts
but on a basic level. It can be described as behavioral engagement
with an expected outcome, where behavior shows the action
people perform to complete the work, outcomes exhibit the
results of individual job behavior. Performance is considered
a multi-dimensional concept. Job performance has received
research attention in the last few decades (41). Effectiveness of
job tasks involves evaluating the results of employee performance
(i.e., financial value of sales). In comparison, productivity is
defined as the ratio of effectiveness to the cost of attaining
the outcome. For example, the ratio of hours of work that an
employee is investing as input and the product they assemble as
output both describe the productivity of an employee. Therefore,
performance must be evaluated separately from efficiency and
effectiveness in productivity (29).
Leadership as a Moderator Between Employee General
Health, Loyalty, and Performance
Different leadership styles and strategies are used by
organizations to improve employee loyalty and the overall
performance of the organization. Different past studies have
examined the impact of leadership and these impacts vary
according to their styles and the effect the employee has
on commitment or loyalty, which significantly affect job
performance (40). Different researchers have also explored
how leadership style has an impact on organizational culture
and organizational performance. Different studies have shown
that in the past, leaders inspire followers to accomplish certain
organizational goals but in recent years it has been observed
that leaders have failed to motivate employees as employees
are much more focused on the concept of working to live and
are thus more focused on rewards (45). This is due to the fact
that employees are so involved in their work that they forget to
take care of their health. The researcher has also talked about
different research that has claimed that employees growing value
is much more on extrinsic rewards and they are not motivated
by the charisma of any kind of leader as they want to seek
outcome. About 70 % of employees thought that they would
get promoted within 2 years in a firm (83). This also shows
that employees have high expectations from the firm where
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they work. Other researchers have found that servant leadership
style has a positive relationship between employee loyalty and
servant leadership style. Different leadership styles might have
a different relationship with job performance depending upon
the situation or the context that employees and supervisors
are in. This also shows that without a leadership style the link
between employee loyalty and job performance can decrease
(37,38). Leaders can create an environment for them to be
motivated toward the achievement of goals. If leaders do not
guide employees, they might be de-motivated and think that they
are not getting incentives, but a leader tries to make sure that
employees understand their work and that their contribution
will pay off in the form of incentives.
Incentives and Employee Loyalty
Different researchers have examined the loyalty of employees.
Some of them have used hotel managers and supervisors to check
loyalty. They found out that loyalty was associated with intangible
aspects. This intangible aspect can be the working environment
of the organization and this environment was linked with their
peers, supervisors as well as customers. They were satisfied with
their jobs because they had opportunities for personal healthcare,
development, and to use strengths that helped them in achieving
their work objectives (31). They also said that employee turnover
was related to there being no opportunities for development.
This study focused on how employee loyalty was linked to
environmental factors that were creating motivation among
employees, leading to them achieving their goals. In the past, it
was believed that performance and employee loyalty was linked
with promotions. But later on, the focus shifted toward the
relationship between the employee and employer and became
much more focused on flexible environments to get better
performance from employees, as they felt more energetic and
healthy when working. Employee loyalty reduces the turnover
intentions among employees. The hospital industry has suffered
an increasing rise in employee turnover, with the main reason
being poor wages (45). Another study showed that employee
loyalty was used as a mediator between commitment and
employee retention and the results of that study showed that
it had a significant effect on both commitment and employee
retention. The study mentioned that compensation and different
social benefits have a greater impact on employee commitment
rather than on retention (37). One of the most important factors
should be taking care of the health of employees in changing
environments such as during the Covid-19 pandemic. Most of
the time, organizations focus on giving financial rewards to their
employees but they sometimes forget that non-financial rewards
are also important to keep employees motivated toward work.
Therefore, both incentives are important when trying to motivate
employees and we need leaders to create an environment for the
employees that enables them to feel motivated toward work (84).
Some researchers have tried to explain incentives and
employee loyalty from a different perspective. They have talked
about how employment and unemployment rates can change
an organization’s point of view (85). One study mentioned that
when there is a higher rate of unemployed in the country then
the chances of the potential job loss become more, at that
time the employer gives employees incentives to gain loyalty.
Organizations try to avoid layoffs and at that time they need
more loyal employees and for that purpose, they provide stronger
incentives. This shows that incentives depend on the leader or
the organizations and much they are encouraging employees to
perform better. This can also depend on the availability of human
capital and when human capital is not easily available in the
market, meaning the employer tries to gain employee loyalty by
giving out benefits to retain talent in the organization (76).
Employee Loyalty and Job Performance
Employees’ work attitudes can predict their outcomes. The
main dimensions linked to employee loyalty are incentives,
healthcare facilities, salaries, promotions, and different individual
characteristics such as the age of the employee, job tenure,
and position. Different studies have focused on perceived
organizational support, customer participation and perceived
that supervisory support can lead to an increase in job satisfaction
and later on, also improve the service quality of employees
(34). Employee loyalty is determined through leadership, human
relations, personal development, better health, creativity, and job
satisfaction. The better these determinants are handled the more
employee loyalty indirectly affects job performance in other ways,
as there is a positive relationship between employee loyalty and
job performance (38).
Employees Incentives and Job Performance
It is suggested in literature on human resource management and
organizational behavior that nonmonetary incentives act as a
tool for motivating employees. When organizations pay attention
to different monetary tools i.e., paid leave, giving bonuses for
having an eye on their health and their family healthcare or other
family, then employees start to perceive that the organization
is supporting them. Therefore, monetary incentives increase the
motivation of employees leading to increased job performance
(78). Non-monetary tools can be appraised by the leader or
environment that leaders provide to their employees. These non-
monetary tools keep employees motivated for a certain time
but if organizations do not give proper incentives to employees
then it will affect their work. Different studies also show that
incentives play a part in the job performance of employees.
A study investigated the link between incentive packages and
employees’ attitudes concluded that several different types of
incentives (monetary, tangible, and non-tangible non-monetary)
play important roles in enhancing employees’ attitudes toward
their work. Different studies have found that there was a linear
correlation between employee loyalty and job performance (72).
Another researcher discusses how job satisfaction impacts
employee loyalty (76–78). They state that different underlying
factors affect job satisfaction, including healthy working
environment, healthy activities, chances of career growth, and
motivation, all of which lead to employees being loyal. Some
researchers believe that job analysis, compensation, and career
planning help to determine employee loyalty. These factors
motivate employees in the workplace and further lead to an
increase in job performance. However, an absence of employee
loyalty can create different issues like an increase in turnover rate
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among employees (71). Organizations might not be concerned
about losing bad performers but if they lose good performers
then that is a major concern for the organization. Therefore, the
organizations are more focused on retaining human talent in
the organization by giving out different facilities to employees
and their families. Later on, the benefits incurred by employee
loyalty will be more from the cost that was invested in them.
Various studies have also shown that employee loyalty is linked
to customer services and developing customer loyalty to ensure
long term profitability for the organization (73).
Expectancy theory by Victor H. Vroom suggests that people
put effort into work when they start to perceive that it will
lead to an increase in their performance, which will eventually
increase the chances of them receiving rewards. Consequently,
an increase in these financial incentives also enhances employee
loyalty, which increases the employee’s performance and reduces
the turnover rate (86). Employees can only be loyal when their
desires are being satisfied by organizations. The organization also
pays attention to these things, as they also believe humans are
an asset and that they need to fulfill their needs to utilize their
skills. In the hierarchy of needs (1954), Maslow concluded that
humans have five basic wants (physiological, safety needs, love,
and belonging, self-esteem, and self-actualization), which can be
satisfied through financial incentives and rewards. Employees
with a sense of recognition from their employers fall under the
heading of self-esteem and, as their needs are being fulfilled, they
will experience increased job satisfaction as well (87–89).
Theoretical Reflection
Two micro theories support the conceptual framework
of our study. These motivational theories explain why
incentives influence employee loyalty, leading toward employee
performance. The first motivational theory is “Maslow’s
hierarchy of need,” which classifies human needs into two types.
First, lower order needs, which are physiological and connected
to safety and security, and second, higher order needs, which
include socialization, self-esteem, and self-actualization. In
this theory, incentives and this type of recognition are given
to employees, and are related to the self-esteem of employees.
These create motivation among them to work hard within the
organization. The second motivational theory is by Herzberg,
who explains two types of factors i.e., motivational factors
and hygiene factors (90). Employees would like to grow in an
organization and if there are chances for growth, advancements,
and recognition they feel motivated to work but hygiene factors
like working environment, quality of interpersonal relation,
and salary are also important along with the motivational
factor (91). Without any one of them, an employee will start
to feel dissatisfied with their job, which will impact their
behavior toward work and can also lead to high turnover among
employees (92).
Another important theory that is highly relevant to our
study is “Vroom expectancy theory.” This theory suggests that
behavior will develop certain attitudes among employees, which
will lead to further actions. This theory outlines that job
performance is based on certain things i.e., skill, personality,
experience, abilities, and knowledge regarding that particular
field (93). The effort an employee puts into work; performance
and motivation are all linked to employee motivation. This
model uses three variables, including expectancy, valence, and
instrumentality. Expectancy is defined as the belief about how
much effort an employee puts into their work that will lead
toward increased performance (90). Valance is defined as the
importance an employee gives or places on the expected outcome.
Instrumentality is defined as an employee’s belief that if they do
well in an organization, a valued outcome will be received. In
this study, an organization motivates employees to work well and
when they do so they receive incentives for the work they have
done. Employees feel motivated by these rewards, which creates
employee loyalty among them as they think organizations care
about their contribution and their needs at the same time. If
organizations do not provide incentives to employees who have
performed well in the organization, they will feel demotivated
and their performance will also decrease, and they will not trust
the organization’s rules and procedures, potentially decreasing
employee loyalty as well (94). Organizations try to motivate
their employees by either providing them with a good healthy
working environment and in this case, with a leader who will
FIGURE 1 | Conceptual framework.
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make sure that the working environment motivates an employee
to increase loyalty and job performance. Therefore, there is a
continuous cycle connecting staying healthy, job performance,
incentives, and rewards to future job performance. The incentives
or rewards determine whether the employees are motivated
enough or, if they are not motivated by the rewards given or
think that the incentives given to them do not reflect what they
have contributed to the organization, then their performance will
decrease in the future (95). Based on the discussed literature, we
formulated a conceptual framework, shown in Figure 1.
Conceptual Framework
H1: Incentives have a positive effect on employee loyalty.
H2: Employee loyalty has a positive effect on job performance.
H3: Leadership can have a positive moderating effect on
employee loyalty leading toward job performance.
H4: Leadership has a moderating effect on incentives and
job performance.
H5: Incentives have a positive effect on job performance.
RESEARCH METHODOLOGY
This research focuses on a quantitative methodology.
Quantitative methods are focused on a systematic way of
collecting data either through questionnaires or surveys.
Quantitative research explains the phenomenon according to
numerical data. It is also defined as the empirical research that
explains a social phenomenon by testing a theory consisting of
different variables. Researchers want to explain the perception
of employees regarding incentives, healthcare, employee loyalty,
leadership, and job performance in the language of statistics and
mathematics. In this research, the researchers have only focused
on the hospital staff’s point of view regarding this matter and
have collected data from them for this research. This research was
a quantitative, descriptive, and cross-sectional study. The overall
methodology of this study is positivism, as it describes the study
through different statistics that are gathered by collecting data.
Research Design
The research design provides an outline for research. It also
provides a guideline for the researchers who are performing that
research (96). While this research focuses on how incentives
can lead to employee loyalty and further contribute to job
performance, this research also focuses on the impact leaders
have on employee loyalty and job performance. Thus, it tries to
describe the relationship between different variables, how they
impact each other, and which variable has the most impact on
the other variables. Therefore, this research used quantitative
methods of collecting data by giving out questionnaires to the
hospital staff. Quantitative research was used for this research
to make the data more representative and to generalize the
information collected and examine the hypotheses proposed
in the literature section. These empirical results could also
help future studies of other developing countries with similar
work conditions. Figure 2 shows the Levene’s test of equality of
error variances.
Research Approach
This research used a deductive research approach, which converts
specific things into general applications. In the deductive
approach, the researcher first finds a theory related to the
conceptual framework and then analyzes that data (10). This will
help in interpreting the data but also in explaining data presented
in the form of graphs and numbers. This deductive approach will
help us explain the results through different theories. It will also
help in accepting and rejecting the hypotheses and explain why
people thought different variables were affecting each other.
Data Collection
The data for this research were collected from primary and
secondary sources. Primary data was collected by giving out
questionnaires to hospital staff e.g. doctors and nurses. The
questionnaires consisted of close-ended questions. In total,
320 questionnaires were collected from respondents and later
analyzed. The reason for using a quantitative method to collect
data was to make sure that we gathered enough information
from the sample, could easily compile data regarding employee
perceptions, and easily analyze the data gathered. Where the
secondary data was gathered through several sources i.e., articles,
and books, the secondary data were used to formulate the
literature review and support the description of findings.
Population and Sampling
A population is defined as a group of individuals that have
certain skills, knowledge, or experiences required for research.
The population chosen for the present research included staff
members working in both public and private sector Hospitals in
Shandong, eastern China. The term population is also defined as a
wide range of people. Every study is based on a certain population
e.g., hospital sector, banking sector, or schools, but collecting data
from such a huge number of people is impossible. For that reason,
researchers divide this population into a sample to easily collect
the required data. Certain techniques are used by researchers to
select samples.
The sampling technique used for the collection of data was
cluster random sampling. Clustering is a useful method of
collecting data and discovering different groups of respondents
that represent the population. The sample might be taken from
a particular city or a particular sector. These clusters help in
dividing the greater population into smaller sections. The later
helps in separating people with similar patterns. Clustering does
not indicate the desired relations that would be valid among
the data beforehand and for this reason, it is thought to be an
unsupervised process (24).
The sample taken for this study is forms of hospital staff i.e.
doctors and nurses from both public and private sector hospitals
of Shandong, Eastern China.
Data were collected via questionnaire to see what impact
incentives have on their job performance or their employee
loyalty and what type of leadership was being provided to them.
The questionnaire was based on the Likert type scale.
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Liu and Liu Incentives on Job Performance, Business Cycle, and Population Health
FIGURE 2 | Normality plot of JPM.
TABLE 1 | Reliability analysis.
N Range Min. Max. Mean SD Variance Skewness Kurtosis
Statistic Statistic Statistic Statistic Statistic SE Statistic Statistic Statistic SE Statistic SE
ELM 320 2.67 1.00 3.67 2.15 0.030 0.537 0.289 0.077 0.136 −0.098 0.272
TSLM 320 4.00 1.00 5.00 2.52 0.047 0.853 0.729 0.402 0.136 −0.228 0.272
MIM 320 4.00 1.00 5.00 2.82 0.040 0.717 0.515 0.200 0.136 0.061 0.272
JPM 320 3.13 1.13 4.25 2.49 0.033 0.591 0.350 0.238 0.136 0.402 0.272
Valid N (listwise) 320
Min, Minimum; Max, Maximum; SE, Standard error; SD, Standard deviation; N, Total sample.
Data Analysis Techniques
For the analysis, data were first screened to see if there were
any missing values. Data collected through questionnaires were
coded and then analyzed using SPSS. The data gathered from
participants were gathered through Likert type scale questions
and was dissolved into high and low groupings and positioned
on scales 1 =strongly agree and 5 =strongly disagree. The
respondents that rated 1–3 were considered high, whereas ratings
from 4 to 5 were considered low. The data were analyzed in
SPSS by applying different tests such as correlation, descriptive
analysis, normality tests, and ANOVA to analyze the gathered
data. Furthermore, confirmatory factor analysis (CFA) was also
performed to analyze different variables.
DATA ANALYSIS
Descriptive Analysis
Descriptive analysis justifies the salient features of the study and
provides a comprehensive summary of the data used in the study
and also shows different statistical measures. Collectively, with
simple graphical analysis, they form the structure of quantitative
analysis of data. Descriptive statistics are easy to understand for
general readers and show the behavior of the data. It is also used
to present the data in a manageable form. Descriptive statistics
cover the different aspects of the data i.e., central tendency, the
measure of dispersion, the measure of normality, and trends
in the data. The section covers the results descriptive statistics
for the hospital sector in Shandong, eastern China. In Table 1
data are analyzed using SPSS software, which illustrates the total
number of observations, arithmetic mean, standard deviation,
the maximum and minimum value of each variable, which
provides an entire description of the data used in the study.
Table 1 represents descriptive statistics for the hospitals
in Shandong, eastern China for a total of 320 observations.
The mean value of the job performance is 2.4948 with a
standard deviation of 0.59176. This means that the value of job
performance can deviate from the mean to either or both sides of
the mean by 0.59176 and the maximum value of job performance
is 4.25 with 1.13 as the minimum value. The mean value of
monetary incentives is 2.8203 with a standard deviation of 0.717,
which again means that the mean value of monetary incentives
can deviate to both sides of the average by 0.717 with a maximum
and minimum value of 5 and 1. Furthermore, the table shows
that the mean value of employee loyalty is 2.1538 with a standard
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Liu and Liu Incentives on Job Performance, Business Cycle, and Population Health
TABLE 2 | Correlation matrix.
MIM ELM TSLM JPM
MIM Pearson correlation 1 0.059 0.307** 0.180**
Sig. (2-tailed) 0.290 0.000 0.001
N 320 320 320 320
ELM Pearson correlation 0.059 1 0.323** 0.240**
Sig. (2-tailed) 0.290 0.000 0.000
N 320 320 320 320
TSLM Pearson correlation 0.307** 0.323** 1 0.222**
Sig. (2-tailed) 0.000 0.000 0.000
N 320 320 320 320
JPM Pearson correlation 0.180** 0.240** 0.222** 1
Sig. (2-tailed) 0.001 0.000 0.000
N 320 320 320 320
**Correlation is significant at the 0.01 level (2-tailed).
TABLE 3 | Tests of normality.
Profession Kolmogorov-SmirnovaShapiro-Wilk
Statistic Df Sig. Statistic df Sig.
JPM Doctor 0.085 171 0.004 0.972 171 0.002
Nurse 0.062 149 0.200* 0.984 149 0.088
ELM Doctor 0.136 171 0.000 0.975 171 0.003
Nurse 0.080 149 0.020 0.983 149 0.056
TSLM Doctor 0.126 171 0.000 0.961 171 0.000
Nurse 0.131 149 0.000 0.973 149 0.006
MIM Doctor 0.147 171 0.000 0.962 171 0.000
Nurse 0.140 149 0.000 0.974 149 0.006
*This is a lower bound of the true significance.
aLilliefors significance correction.
TABLE 4 | Levene’s test of equality of error variances.
F df1 df2 Sig.
Dependent variable: JPMa
2.779 13 306 0.001
Tests the null hypothesis that the error variance of the dependent variable is equal
across groups.
aDesign: Intercept +MIM +ELM +MIM *ELM.
deviation of 0.537 with a minimum and maximum value of 3.67
and 1 in contrast, transformational leadership has a mean value
of 2.6167, with a standard deviation of 0.853 and has a minimum
value of 1 and maximum value of 5.
The correlation table above clearly shows that the variables
used in the study are related to one another, in other words,
the independent variable influences the dependent variable.
Simultaneously, the mediating and moderating variables also
influence the independent and dependent variables. The tables
above illustrate that there is a 0.180 correlation between job
performance and monetary incentives, which means that if
monetary incentives are increased by 1% job performance will
increase by 0.180% hence it has an impact on job performance.
Furthermore, the correlation matrix states that transformational
leadership does influence job performance and has a greater
correlation with dependent variables with a value of 0.222, apart
from this, employee loyalty also has a positive correlation with
job performance, with a value of 0.240 apart from this, the value
of correlation is significant because the pvalue is <0.05. Hence,
statistics prove that the variables do have a relationship.
Descriptive Analysis
Normality is one of the assumptions of running the ANCOVA
model on data. It states the error between observed and predicted
values are normally distributed. The hypotheses for the normality
are as follows (see Table 1):
Ho =the error term is not normally distributed.
H1 =the error term is normally distributed.
To use the 320 observations from the hospital sector, data were
analyzed to check whether the concerned variables are normally
distributed or not.
The normality assumption was checked and is supported by
different tests applied to the study, among them Shapiro wilk test
is simple, effective, and is a standard test for checking normality
(see Tables 2,3). Observing the size and nature of the data,
Shapiro Wilk and Kolmogorov-Smirnov tests were applied to
determine the normality of data, as shown in the table below.
The table below showed that the majority of the significant values
were <5%, which means the data are not normally distributed,
but the table also shows that the pvalue in terms of nurses is
significant and proves that data are normal (Tables 2,3). Hence,
the null hypothesis has been rejected and an alternate hypothesis
is accepted.
Test of Normality
To check the homogeneity of variances of the data collected,
Levine’s test of equality of error variances was applied (Table 4).
The table below clearly shows that the results are significant,
indicating that the mean pvalue is <0.05, which proves that
homogeneity of variances exists in the collected data (see
Figures 3,4).
Confirmatory Factor Analysis
The following table reports the analysis between our variables.
The coefficient value between depending on and independent
variable that is job performance and monetary incentives is
0.04, which shows every unit increase in monetary incentives
the job performance increase by 0.04 percent at a 5%
significance level. The result shows that employee loyalty plays a
mediating role in job performance through monetary incentives
at a 5% significance level. Furthermore, the coefficient of
transformational leadership between monetary incentives and
job performance plays a moderating role of 0.09 at a 5%
significance level (Figure 3).
RESULTS
The data collected in the study were analyzed using SPSS
software, regression, and ANOVA analysis techniques because
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Liu and Liu Incentives on Job Performance, Business Cycle, and Population Health
FIGURE 3 | Normality plot of JPM.
FIGURE 4 | CFA model.
we are measuring the direct impact of monetary incentives
on job performance with employee loyalty as a mediator
and transformational leadership as a moderator between job
performance and employee loyalty. The results are shown in
Table 7.
Hypothesis Testing
To check the hypothesis, several values were used,
from the model, the basic value used for analyzing the
hypothesis are the beta coefficients, Adjusted R square, and
R square.
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Liu and Liu Incentives on Job Performance, Business Cycle, and Population Health
TABLE 5 | Model summary.
Model R R square Adjusted R square Std. error of the estimate Durbin-Watson
1 0.311a0.097 0.088 0.56512 1.774
aPredictors: (Constant), TSLM, MIM, ELM.
bDependent variable: JPM.
TABLE 6 | Coefficients.
Model Unstandardized coefficients Standardized coefficients t-stat Sig. Collinearity statistics
B Std. error Beta Tolerance VIF
Coefficientsa
1 (Constant) 1.513 0.177 8.543 0.000
MIM 0.109 0.046 0.132 2.346 0.020 0.904 1.106
ELM 0.213 0.062 0.193 3.419 0.001 0.894 1.119
TSLM 0.083 0.041 0.119 2.010 0.045 0.812 1.231
aDependent variable: JPM.
Table 5 clearly shows that healthcare, monetary incentives,
employee loyalty, and transformational leadership affect job
performance. The value of adjusted R square that is 0.097 means
that the 100% fluctuations in job performance out of which
9.7% fluctuations are due to monetary incentives, employee
loyalty, and transformational leadership, support the hypotheses
of this study.
Furthermore, the beta coefficients from the model were used
to prove each hypothesis separately.
For testing hypotheses 1 and 5, the beta coefficient 0.132
in Table 6 indicates that when the monetary incentives are
increased by 1 unit the job performance increases by 0.132. It
showed that the value 0.132 is positive, which also proves that
there is a positive relationship between monetary incentives and
employee loyalty at a significant level of 0.020 <0.05, hence we
accept our hypotheses 1 and 5 (Table 6).
Hypothesis 2: there exists a positive relationship between
employee loyalty and job performance. The model in Table 6
shows that the beta coefficient between job performance and
employee loyalty is 0.193 at a significance level of 0.001 <0.05,
which means that the 1 unit increase in employee loyalty causes
the job performance to increase by 0.193 hence our second
hypothesis is also accepted (Table 7).
For testing Hypotheses 3 and 4, the beta coefficient 0.119
at a significance level of 0.045<0.05 in Table 6 shows that
transformational leadership does moderate employee loyalty
incentives and job performance. The value 0.119 means that
when transformational leadership increases by 1 unit positively
the job performance of an employee increases by 0.119, which
provides logical proof of Hypotheses 3 and 4.
DISCUSSION AND CONCLUSION
The present study examined the impact of incentives on the
healthcare of employees, their loyalty, and job performance. In
TABLE 7 | ANOVA.
Model Sum of squares df Mean square F Sig.
ANOVAa
1 Regression 10.791 3 3.597 11.264 0.000b
Residual 100.918 316 0.319
Total 111.709 319
aDependent variable: JPM.
bPredictors: (Constant), TSLM, MIM, ELM.
this study, we used transformational leadership as a moderator
to see what impact both incentives and leadership have on the
job performance of an employee. The data for this study were
collected from doctors and nurses from both the public and
private sectors to see the impact that monetary incentives and
leadership have on employee loyalty and job performance. The
collected data were then analyzed in SPSS through descriptive
statistics, correlation matrix, and by doing confirmatory factor
analysis and as well as through regression and ANOVA model.
After applying these analysis tools several statistics were shown
by the model such as the correlation matrix, which proved that
a relationship among the variables used in the study exists. All
the values in the correlation matrix showed that there was a
link between monetary incentives and job performance and that
leadership did play a moderating role between incentives and job
performance. The correlation matrix also showed that there was
a 0.180 % correlation between job performance and incentives
including better healthcare. The correlation matrix also showed
that transformational leadership had a greater correlation with
the dependent variable, apart from the regression model, which
gave the healthy justification for accepting all the hypotheses
since all the beta coefficients were aligned with the hypotheses
and showed a positive relationship among the variables. The
key point of the discussion is that this study provides helpful
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Liu and Liu Incentives on Job Performance, Business Cycle, and Population Health
material for managers and employers to understand the behavior
of employees regarding their job performance. Organizations
could increase employee loyalty by giving meaningful incentives
to their employees. Additionally, a good and effective allocation
of supervisors to a particular group of employees can increase
their job performance and their loyalty toward the organization.
Given that the research subjects of this study were health workers
from Shandong Province, eastern China, their increased job
performance and loyalty to affiliated hospitals could further
increase their service quality, enabling higher patient satisfaction.
The first limitation of our study is that it is cross-sectional.
The results might be different in the case of a longitudinal
study. Therefore, it is recommended that further researchers
undertake a longitudinal study on the same variables. Another
limitation of our study is that it is quantitative and only
describes the relationship between different variables. Future
researchers should undertake an in-depth study examining
the reasons for the variables affecting each other in this
manner. Apart from this, the study was conducted in a
few public and private sector hospitals in Shandong and the
sample size of the study was small. Thus, future research
could use a larger sample size for the same variables. In
addition to this, the researchers cannot generalize the findings
for this small sample, meaning further research should be
conducted in different countries to explore how different
factors vary and affect different contexts. Future studies
should also compare how these factors affect semi-government
hospitals. Further future research could also explore the impact
of these variables on administration staff working in the
hospital sector.
DATA AVAILABILITY STATEMENT
The original contributions presented in the study are included
in the article/supplementary material, further inquiries can be
directed to the corresponding author.
AUTHOR CONTRIBUTIONS
WL conceived the main idea and collected the data for analysis.
YL suggested the methodology and finalized the manuscript. All
authors are agreed on publication.
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