When does trust in leader foster innovative work behaviour in public hospitals? Role of employee engagement and high-performance work systems

This study examines how trust in leader influences doctors’ innovative work behaviour (IWB) in public hospitals, identifying employee engagement as a mediating mechanism and perceived High-Performance Work Systems (HPWS) as a contextual moderator. Drawing on the Social Exchange Theory (SET) and the Ability–Motivation–Opportunity (AMO) framework, the study explains how relational and structural factors jointly shape IWB in public healthcare settings.

A deductive, quantitative design with a cross-sectional approach was employed. Data were collected through a self-administered survey from 270 doctors working in public hospitals in Sindh, Pakistan. Data were analysed using SmartPLS to assess mediation and moderation effects.

Trust in leader was positively associated with employee engagement, which in turn predicted IWB, supporting the mediating role of engagement. However, perceived HPWS negatively moderated the engagement–IWB relationship, indicating that higher levels of HPWS weakened the positive effect of engagement on IWB.

First, the cross-sectional design limits causal inference among trust in leader, employee engagement, HPWS and IWB. Longitudinal or time-lagged research could better capture the dynamic and reciprocal nature of these relationships. Second, the findings are based on public-sector hospitals in Sindh, Pakistan, which may limit generalisability to other institutional or cultural contexts. Future studies could replicate the model across sectors and regions to assess contextual robustness. Third, although a negative moderating effect of HPWS was observed, the study relied on perceived measures and did not directly assess implementation quality or system strength. Multi-level or mixed-method approaches could provide deeper insight into how HR system characteristics shape the engagement–innovation link.

The findings also carry practical implications for public healthcare administrators. First, building and maintaining trust between leaders and doctors should be prioritised, as relational trust directly and indirectly supports IWB. Leadership development programmes should therefore emphasise credibility, fairness and transparent communication. Second, fostering employee engagement is essential for sustaining innovation. Hospital management can support engagement by recognising contributions, encouraging participation in decision-making and creating opportunities for professional development. Finally, the results suggest that merely establishing formal HR systems may not automatically enhance innovation. Policymakers and HR departments should focus not only on designing HPWS practices but also on ensuring their consistent and credible implementation.

In public healthcare settings, aligning HR practices with professional norms and allowing sufficient autonomy may be critical to ensuring that structural systems support, rather than constrain, innovative behaviour. Collectively, by promoting IWB among doctors, these practices may ultimately contribute to improved healthcare service quality and patient outcomes, thereby generating broader societal benefits.

By integrating the SET and the AMO framework in a moderated mediation model, this study advances the understanding of how trust-based relational mechanisms and perceived formal HR systems interact to influence IWB in public-sector healthcare contexts.