The Influence of Socio-demographic Factors and Hospital type on Islamic Work Ethics of Healthcare Providers at Emergency Departments in Jordan

. Purpose: Islamic work ethics (IWE) has been an area of attraction for scholars exploring Muslim employees’ attitudes and behaviors. This study aims to examine the IWE of healthcare providers (HCPs) in Jordan’s public and private emergency departments, and test the influence of socio-demographic factors and hospital type on IWE. Methodology: A descriptive cross-sectional study was used. Data were collected from the HCPs in Jordan middle district hospitals using a self-administered questionnaire. In total, 297 questionnaires were completed and returned for analysis. Descriptive statistics, regression analysis, and independent sample t-test were used to analyze the data. Findings: The HCPs in private EDs showed a higher commitment to IWE than public EDs HCPs, and statistical differences were found between the public and private EDs. Multiple linear regression analysis showed that socio-demographic factors (age, gender, income level, professional classification, and social status) do not significantly influence IWE. Only the hospital type has a significant negative influence on IWE. Conclusion: HCPs in private EDs showed a high level of commitment to IWE than public HCPs. Statistical differences were discovered between the public and private EDs. The regression analysis showed no effect of socio-demographic factors on the IWE. Originality/Significance: This is perhaps the first paper investigating the influence of socio-demographic factors and hospital type on IWE of HCPs at EDs in Jordan. Research Limitations/Implications: This paper was limited to HCPs working in eleven hospitals in Jordan’s middle district. The study’s findings were based on the respondents’ honesty and truthfulness when


Background of Study
Hospital's emergency department (ED) is the front line of healthcare and plays a vital role in saving lives. Research has indicated that ED stands for half of all hospital inpatient admissions of emergency care. All Muslim HCPs, regardless of status, have a shared responsibility to display IWE in the workplace against one another and patients (Al Smadi et al., 2021). IWE shows a positive relationship with numerous organizational behaviors, including employee inducement, job performance, job satisfaction, and affective commitment (Aflah et al., 2021;Hayati & Caniago, 2012;Taufail et al., 2018). However, little is known about factors that could predict employees' commitment to IWE, such as socio-demographic factors (Aminnuddin, 2019;Mohammad et al., 2015). Most studies focused on measuring IWE, its effect, and interaction with other variables rather than factors that may predict it (Aminnuddin, 2019). Socio-demographics seem to be more interesting factors that attract scholars' attention in different fields of study. Some studies were conducted to identify the influence of sociodemographic factors on variables such as ethical behaviors (Lokman et al., 2018), job satisfaction (Al Smadi et al., 2022), job performance (Amegayibor, 2021), Decision-Making (Rajiah & Venaktaraman, 2019), and ethical perceptions (Serwinek, 1992).
Furthermore, this study aims to investigate if there is a difference between the private and public HCPs' commitment to IWE in the EDs of the middle district of Jordan. The difference between public and private healthcare facilities is debatable around the world. Public and private hospitals' performance differs from country to country, and several reasons can contribute to these differences (Basu et al., 2012). In Jordan, there is a clear distinction between the public and private healthcare systems; this distinction can be observed in healthcare workers' distribution and health insurance coverage between the public and private sectors. The High Health Council (2019) of Jordan indicated that the total number of physicians is 26885, with around 65 percent working in the private facilities, 33 percent in public and 2 percent in the international and cherty facilities. Furthermore, there are 27769 registered nurses, roughly 52 percent working in private facilities, 44 percent in the public facilities, and 4 percent in the international and cherty facilities. Despite the imbalance in worker distribution between the public and private facilities. Approximately 75% of the population obtains healthcare from public facilities, compared to 21% from private facilities and 4% from missionaries (Rawabdeh & Khassawneh, 2018).
Understanding the difference between HCPs' attitudes and behaviors for public and private healthcare facilities benefits healthcare management, economists, decision-makers, policy advisers, customers, the healthcare workforce, and professional associations. Identifying the differences between the public and private hospitals will have some implications that can improve the quality of healthcare, provide an opportunity to increase cooperation and gain mutual experiences, or either it can be used as a benchmark for future studies. Furthermore, Rainey et al. (1976) indicated that knowing the differences between public and private healthcare facilities have benefits for management exercise, and more notably, there are benefits to keep making public and private evaluations, not in denial of efforts but to gain knowledge of healthcare facilities and their management and increase it.
Therefore, this study aimed to (i) examine the IWE of HCPs in public and private EDs in the middle region of Jordan, (ii) ascertain if there are any significant statistical differences in IWE between the public and private EDs, and (iii) test the association between socio-demographic factors and hospital type with IWE score, including professional classification, gender, social status, age, monthly income, and hospital type.
This study is structured as follows: The background of the study is discussed in this part. The literature review is discussed in the next section. The study method is covered in the third section. The study's findings were given in the fourth section. The fifth section is dedicated to discussing the findings. The limitations and recommendations are discussed in section 6. The final section focused on the conclusions as well as contributions and practical implications of this study.

LITERATURE REVIEW
IWE have been given considerable attention in the research literature. The ethics that Islam encourages are universal and applicable to any work setting (Khadijah et al., 2015). Several researchers have examined the influence of IWE on employees' attitudes and behaviors, such as intrinsic motivation, employee work engagement, innovation capability, job satisfaction, and organization loyalty. The subsequent sub-section provides an overview of IWE literature.

Empirical studies of IWE
Before discussing the empirical studies of IWE, it is essential to highlight that Ali (1988) was the first to write on the scale and measurement of IWE. Ali has used a 46-item scale to measure the IWE without indicating any dimensions or subscales. Later a shortened version of the scale was developed, and a version with 17 items was created (Ali, 1992). Furthermore, according to a literature review, Ali's 17-item tool is the most commonly used scale for IWE study (Usman et al., 2015). Chanzanagh and Akbarnejad (2011) measured the IWE to Iran export development bank staff. Only 262 of the 1000 employees invited to participate in the study returned the questionnaire. According to their findings, Iran employees had a greater rate of IWE than the rest of the world, and low-income employees are more committed to IWE than middle-and high-income employees. Haroon et al. (2012) investigated the link between IWE and job satisfaction across nursing employees in Pakistan's health sector in the healthcare context. The findings showed a strong relationship between IWE and job satisfaction. Rokhman and Hassan (2012) explored the effect of IWE on the insight of justice among workers in Islamic microfinance organizations in Indonesia. They concluded that IWE positively influences the workers' job satisfaction and organizational commitment. Hayati and Caniago (2012) examined the influence of IWE on intrinsic motivation, job satisfaction, organizational commitment, and job performance. The empirical results of their research disclosed that IWE had a more strong influence on intrinsic motivation and organizational commitment than job satisfaction and performance. Imam et al. (2015) explored the relationship between IWE on worker performance by employing two dissimilar models of working personality X and Y. They successfully proved that IWE could significantly affect worker performance. Moreover, IWE also affected the personality of X and Y workers, which strongly affected worker performance. Khadijah et al. (2015) investigated the work ethics profile of workers in Malaysia. They used a self-developed scale for measuring the IWE. The scale consists of effort, teamwork, honesty, and accountability. The results of this research showed that banks' workers committed to all IWE aspects. Mohammad et al. (2016) investigated whether IWE can moderate the relationships between organizational justice and organization citizenship behavior. Their findings revealed that justice directly affected citizenship behavior towards individuals and organizations alike. These relationships were more efficient for staffs that were high in IWE and weak for staffs that were low in IWE. Taufail et al. (2018) inspected the buffering role of IWE on job insecurity-job outcome relationship. The results confirmed that IWE has a significant positive effect on job satisfaction and job performance. Further, the results confirmed that IWE moderates the negative impact of job insecurity on job satisfaction and job performance. Riaz et al. (2020) examined the moderating role of IWE on the relationship between the project team members' stress and the project performance. The results showed that IWE has a significant effect by moderating the relationship between the project teams' stress and project performance. Aflah et al. (2021) investigate the role of IWE in influencing Islamic motivation, affective commitment, job satisfaction, and employee performance. The results showed that IWE positively influences Islamic motivation, job satisfaction, and affective commitment. Yousef (2001) examined the moderation role of the IWE on the relationship between organizational behavior and job satisfaction. Yousef discovered that organizational commitment and job stress were directly impacted by IWE. The IWE was measured using Ali's (1988) long version scale. In total, 30 public, private, and combined businesses received 600 surveys. He pointed out that IWE moderates the relationship between organizational commitment and job satisfaction. Further, the findings showed that employees in public organizations showed high commitment to IWE than those in private organizations. Additionally, the findings showed that service firms' employees showed more remarkable dedication to IWE than those in industrial organizations.

IWE & Socio-Demographic Factors
Aminnuddin (2019) indicated a contradiction related to the effect of individual differences on ethical behavior. Ali and Al-Kazemi (2007) examined the IWE and loyalty of 762 directors randomly chosen from public and commercial sectors in Kuwait. The findings revealed that expatriates outperformed Kuwaiti managers on the IWE, while men outperformed women on the IWE. Furthermore, Ibrahim (2015) investigate the difference between banks' employees' commitment to IWE according to the demographic variables in Aceh, Malaysia. His study results indicated no statistical difference between the employees' commitment to IWE according to gender, age group, educational level, length of experience, and income level.
Furthermore, Yousef (2001) looked into IWE for 425 workers from various organizations in the United Arab Emirates (UAE). He found that age, work experience, and level of education all significantly boost the commitment to IWE. Further, he indicated that Arab expats are more committed to IWE than UAE natives or Asian expatriates. However, when it came to gender, he discovered no link between gender and IWE commitment. Alhyasat (2012) looked at the impact of demographic variables on 204 Jordanian Press Foundations employees. He found that demographic characteristics such as sex, age group, experience, and marital status had no statistically significant effect on IWE. However, he discovered a statistically significant effect of education level on the commitment to IWE; workers with bachelor's degrees are more committed than those with high school education and PhDs.
Similarly, Aminnuddin (2019) used socio-demographic factors such as gender, education level, age and employment history as predictors of IWE behavior of 370 teaching staff at public schools in Brunei, Malaysia. Aminnuddin claimed that by identifying the role of socio-demographic factors as predictors, IWE behavior could be understood more comprehensively. However, the founding indicated that demographic characteristics were not significant predictors of IWE. Alhyasat (2012) examined the role of IWE in rising organization citizenship behavior at Jordanian press organizations. The survey showed that personnel in Jordanian press organizations had a remarkably high level of commitment to IWE. Moreover, Yaseen et al. (2015) examined the IWE and organizational commitment of Jordanian Islamic bank managers and heads of divisions. The study found that IWE positively impacted organizational commitment, and Jordanians were affected by Islamic instruction and ethics, regardless of their religions.

Jordan IWE studies
According to the presented literature, IWE positively correlates with job satisfaction, job performance, organization citizenship behavior, and others. However, no studies were conducted on predicting IWE using socio-demographic factors apart from Aminnuddin's (2019) study. Furthermore, there is paucity of scientific studies investigating the IWE of workers in Jordanian literature, and non-studies were found investigating the IWE for the HCPs in the EDs context. The purpose of this study is to examine the IWE of HCPs in EDs for public and private hospitals in the middle region of Jordan, compare the level of commitment HCP to IWE for public and private EDs, and test the association between socio-demographic factors including professional classification, gender, social status, age, monthly income, and hospital type and IWE score of HCPs.

Study Design
This cross-sectional quantitative study investigated the difference between HCPs' commitment to IWE in public and private EDs of the middle district of Jordan. In addition, it assessed the influence of socio-demographic factors and hospital type on the IWE of HCPs.

Sample and Data Collection
Convenience sampling was used to gather the data from public and private EDs. Eleven hospitals were involved in the study, six of which were private and five of which were public. Participants in the study were from the EDs of the appointed hospitals and included physicians, nurses, paramedics, radiologists, lab technicians, and administrative staff. A self-administration questionnaire attached with a cover letter and consent form was used for data collection. Respondents expressed their opinions on a 10-point Likert scale (1 = strongly disagree, 10 = strongly agree). Data was collected using the convenience sampling technique. In total, 475 surveys were shared with the HCPs in the period June 20, 2020, to August 10, 2020. Altogether, 235 surveys were distributed in public EDs and 240 in private EDs. In total, 297 questionnaires were filled out and sent back to the researcher. Public EDs had a response rate of 63% (n=150), whereas private EDs had a response rate of 61% (n=147). The Jordanian Ministry of Health's Research Ethics Committee granted ethical permission on June 7, 2020.

Study Instrument
IWE was measured using Al Smadi et al. (2021) IWE instrument. This instrument consisted of three dimensions and 17 items: obligation of HCP to their patients (seven items), obligation of supervisors to their subordinates (five items) and obligation of HCP to their colleagues (five items).
Furthermore, item four, "The health care providers have always avoided any corruption" of the third dimension obligation of HCP to their colleagues was removed from the analysis as this item seemed conceptually unrelated to the dimension. The Cronbach's alpha was calculated for the IWE scale for public and private participants. The results showed that Cronbach's alpha for public and private was 0.95, indicating high reliability.

Data Analysis
The data were inserted into an Excel sheet before being exported to IBM SPSS Version 25. Because the missing data was less than 5%, a series of mean values was used in their place (Hair et al., 2014). In addition, 11 cases that were outliers were deleted from the data set. After the data had been updated and cleaned, it was possible to calculate frequencies, percentages, means, standard deviations (SD), and Cronbach's alpha.
Furthermore, the study used an independent sample t-test to assess the mean difference between hospital types (public & private) based on IWE aspects. The link between IWE and socio-demographic variables such as age, professional category, gender, social status, monthly income, and hospital type was also examined using multiple linear regressions (Alrawashdeh et al., 2021;Aminnuddin, 2019).

RESULTS AND FINDINGS
The demographic analysis for the study's respondents revealed that the male respondents in public hospitals were 83(58%) and private hospitals were 85 (59.4%). Further, the married HCPs in public were 97 (67.8%), and in private were 57 (39.9%). Over half of private EDs were nurses, 87 (60.8%), and around 61 (42.7%) of participants of public EDs were nurses. More information about the demographic profile is available in Table 1.
Descriptive statistics such as means and SD were estimated for dimensions and items of the IWE scale for public and private EDs, as shown in Table 2. The commitment of IWE was graded as: 1-2.8 = very low IWE, 2.81-4.6 = low, IWE, 4.61-6.4= medium, IWE, 6.41-8.2 = high, IWE and 8.21-10 = very high, IWE. The lowest mean scores were to the obligation of supervisors dimension in both public and private EDs, 6.88 (SD 1.87), and 7.48 (SD 1.76), respectively. The highest mean score in public EDs was for the obligation of HCP to their patients, 7.51 (SD 1.70), and the same for private EDs 7.93 (SD 1.52). The HCPs in private EDs scored highly commitment on IWE over the public EDs for all dimensions. However, regarding the means differences between the public and private EDs, the results indicate that HCPs have a high commitment to IWE.
The mean difference in IWE between public and private EDs was determined using an independent sample t-test. The findings revealed a statistically significant difference (p<0.05) between public and private EDs in terms of HCP obligations to their patients and the obligation of supervisors. Furthermore, no statistically significant differences in HCP obligations to their colleagues were discovered (p>0.05). Table 3 shows the results of the independent sample t-test.   Tables 2 and 3 showed a significant difference in HCPs' level of commitment on IWE regarding the obligation of HCP to their patients between public and private EDs (t 284 = 2.22, p<0.05). HCPs who work in private EDs reported a significantly greater positive level of commitment to obligation to their patients (M = 7.93, SD = 1.52) than HCPs who work in public EDs (M = 7.51, SD = 1.70). The findings also showed a significant difference between public and private EDs in the supervisors' commitment to their responsibilities (t 284 = 2.78, p<0.05). Supervisors who work in private EDs reported significantly greater commitment on IWE with (M = 7.48, SD = 1.76) than HCPs who work in public EDs (M = 6.88, SD = 1.87). Moreover, the results indicated no significant difference in HCPs' commitment level regarding their obligation of HCPs to their colleagues between public and private EDs (t 284 = 1.83, p > 0.05). HCPs who work in private EDs reported a close level of commitment on obligations to their colleagues (M = 7.64, SD = 1.69) to HCPs who work in public EDs (M = 7.26, SD = 1.79). Table 4 shows a summary of regression analysis results. The analysis revealed that all predictor variables (age, professional classification, gender, social status, and monthly income) except the hospital type could significantly predict the IWE of HCPs in ED. All p-values of the selected predictors are above 0.05, except the p-value of the predictor for hospital type, which is 0.018, meaning that being a worker in a public hospital is a predictor for a lower commitment on IWE ( = -0.16, p = 0.018, 95% CI: -0.97, -0.09).

Discussion of the Study Findings
This study indicated that HCPs in private EDs have higher levels of IWE as compared to HCPs in public EDs. This result contradicts with that of Yousef (2001), who discovered that workers in governmental agencies demonstrated greater support for IWE than those in private businesses. Further, HCPs showed a high level of commitment to IWE in public and private EDs, in line with the results of Alhyasat (2012), and Khadijah et al. (2015). The independent sample t-test indicated a statistical difference between public and private EDs in two dimensions of the IWE scale, i.e. obligation of HCP to their patients and the obligation of supervisors. However, there was no statistical difference in the obligation of HCP to their colleagues. These results can be linked to the characteristics of the workplace, as the public EDs are generally overcrowded, have limited resources, shortage of staff and specialty doctors, lack regular training, lack incentives for performance appraisal, workplace violence, and other such issues that are relatively less prevalent in private EDs (High Health Council, 2019).
The results revealed no statistical difference in the obligation of HCPs to their colleagues, which may indicate that HCPs fulfil their Islamic obligation toward their colleagues in the workplace regardless of the ED type. This result is in some way in line with that of Al Smadi et al. (2022). They find no statistical difference between the satisfaction of HCPs regarding communication and relationships in public and private EDs.
The analysis of the socio-demographic factors including, professional classification, gender, social status, age, monthly income and hospital type, indicated that the hospital type is the only significant predictor for IWE (p-value = 0.018). Further, working in a public hospital is a negative predictor of IWE ( = -0.16). Moreover, the results showed an insignificant prediction of other socio-demographic factors (age, care professional, gender, social status, and monthly income). The insignificant results of socio-demographic factors of HCPs apart from hospital type on IWE are in line with Aminnuddin's (2019) results. These results may be interpreted in light of the Qur'ānic teachings of equality of all. Allah decreed: "Whoever does an evil deed will only be paid back with its equivalent. And whoever does good, whether male or female, and is a believer, they will enter Paradise, where they will be provided for without limit" (40:40). Furthermore, Prophet Mohammed (PBUH) sayings "All of you are shepherds, and each of you is responsible for his flock. A man is the shepherd of the people of his house and he is responsible. A woman is the shepherd of the house of her husband and she is responsible. Each of you is a shepherd and each is responsible for his flock." (Al-Bukhari) 1 HCPs seem to have an obligation to their patients, and this obligation come from medical ethics (Bankowski, 1989). However, Muslim HCPs have an extra obligation that comes from their religion. IWE stresses Muslim HCPs to do their work well and avoid deception or malpractices in the workplace (Aldulaimi, 2016;World Health Organization, 2005). The Prophet PBUH stated, "God has ordained the doing well of everything."(Al-Tirmidhi) 2 . Further, Muslim HCPs are responsible for providing care to all patients equally irrespective of their color, religion, race, political association, etc., as Allah has decreed, "We have sent our messengers with clear signs and sent down with them the Book and the Scale, so that men may stand in equity" (57:25), "God enjoins equity and charity" (16:90), and "And be fair; God loves those who are fair" (49:9). Furthermore, Prophet Mohammed (PBUH) stated, "No one of you becomes a true believer until he likes for his brother what he likes for himself."(Al-Bukhari and Muslim) 3 . Moreover, Muslim HCPs are responsible for directing the patients to appropriate services and abstaining from misguiding patients in the hopes of gaining personal benefits such as receiving bribery. Muslim healthcare providers must demonstrate and practice cooperation with one another and with patients, as cooperation is critical and can influence the quality of healthcare services (Mosadeghrad, 2014). Allah has decreed in the Qur'ān, " Cooperate with one another in goodness and righteousness, and do not cooperate in sin and transgression." (5:2). Finally, consulting patients and involving in decisions regarding their health issues is in line with the IWE; Allah says: "and whose affair is [determined by] consultation among themselves" (42:38). Consultation and engaging the patients about their health issues and decisions will make them feel valuable and important, boosting their self-esteem and strengthening their commitment to the treatment plan (Vahdat et al., 2014).
Supervisors have many obligations in the workplace. One of the primary obligations is towards their subordinates. Supervisors need to create a balance between the patients' needs and subordinates' wellbeing and health. The Prophet PBUH said, "All of you are shepherds and each of you is responsible for his flock. A man is the shepherd of the people of his house and he is responsible. A woman is the shepherd of the house of her husband and she is responsible. Each of you is a shepherd and each is responsible for his flock."(Al-Bukhari( 4 . Supervisors need to ensure that patients receive the appropriate services in ED, which ensures better healthcare quality and outcome. Supervisors have to avoid injustice in the workplace, avoid politics, and treat all employees fairly and with respect and without discrimination regarding gender, age, experience, or profession. Supervisors should undertake consultation in the work since it benefits both HCPs and organizations. It boosts employee self-esteem, strengthens commitment, and encourages people to engage in more citizenship activities by making them feel valuable and essential. Consultation can also help to decrease mistakes, increase efficiency, and enhance outcomes (Ibrahim, 2015;Wahab, 2012). Supervisors must encourage cooperation between themselves and subordinates. Excellent cooperation benefits healthcare institutions by promoting job quality and teamwork, instilling harmony and respect for each member's rights, and increasing constructive feedback.
In addition, HCPs showed that they have an Islamic obligation toward each other in the workplace. HCPs need to fulfil this obligation to be true believers. HCPs need to treat each other with respect, justice, honesty, trust, and cooperation. Moreover, HCPs have to display cooperation in the workplace. A high level of cooperation fosters positive relationships among HCPs in the hospital, resulting in increased productivity (Aldulaimi, 2016;Ibrahim, 2015). Furthermore, Muslim HCPs have an obligation toward each other in the workplace. Immoral activities such as false pride, lying, false testifying, egotism, and self-conceit must be avoided by Muslim HCPs (Ibrahim, 2015).

Conclusions
IWE became an interest for scholars who study organizational behavior. This study investigated the IWE for HCPs in public and private EDs in Jordan. The results indicated that HCPs have a high level of commitment to IWE in both public and private EDs. However, some significant statistical differences were found between HCP in public and private EDs.
Furthermore, regression analysis revealed that working in public EDs is a negative predictor of HCPs' commitment to IWE compared with the private HCPs, and other socio-demographic factors: age, care professional, gender, social status, and monthly income do not have a significant effect on predicting the IWE. Finally, paying attention to IWE in the workplace and linking the work performance with one's religious obligation will positively impact the HCPs' attitudes and behaviors toward each other, patients, and the whole organization.

Contribution of the Study
This study enriches the theory of IWE, especially from the Islamic ethics perspective of HCPs in Jordan and Arab culture, highlighting the importance of IWE and how it interacts with medical ethics, comparing the level of IWE between the public and private HCPs in EDs, and identifying the influence of socio-demographic factors and hospital type in predicting the IWE.

Practical Implications
This study aimed to measure the IWE of HCPs in EDs of middle district hospitals in Jordan. IWE is one of the remarkable factors that is postulated to have a positive influence on essential factors, such as job satisfaction, job performance, organization citizenship behavior, etc. Healthcare managers, human resource professionals, policymakers, researchers, and others can benefit from this study's results. Measuring the level of IWE of HCPs can allow healthcare managers to improve the positive behaviors of the organizations to which these HCPs belong, which in turn can have a positive outcome for EDs and the patients. The results can be used as a benchmark for future studies related to work ethics and IWE. Furthermore, identifying the differences between the public and private healthcare providers can assist improve healthcare quality, provide an opportunity to increase cooperation, and gain mutual experiences between the different sectors.

Limitations and Recommendations
This study only included eleven EDs of public and private hospitals and was only conducted in Jordan's middle region. The results of this study were reliant on the respondents' truthfulness and honesty when filling out the survey. Furthermore, this study relied entirely on HCPs who had the time and desire to participate and did not employ any probability sampling technique. This study investigated the IWE of HCPs from their perspective and how they viewed themselves. This study could be expanded to include larger sample sizes and responders from various hospital divisions. In addition, a study can be conducted on the employees from other industries such as manufacturing and education, and a comparative study among the different industries can be executed. Finally, one of the most important issues that need to be considered by future research is how the patients or customers view the HCPs commitment to IWE, as all available scales evaluate the IWE from the providers' side, which does not provide the complete picture of IWE.