Organizational Factors, Fulfilment of the Psychological Contract and
Quality of Patient-Care in Public Hospitals
Dr. Manisha Agarwal,
Dr. Ajay Kumar Khanna,
&
Abhishek Sharma
About the Authors
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Dr. Manisha Agarwal: Associate Professor, Department of Psychology, Faculty of Social Sciences, Banaras Hindu university, Varanasi-221005, India; email:
Dr. Ajay Kumar Khanna: Professor & Head, Department of General Surgery, Institute of Medical Sciences, BHU, Varanasi-221005, India
Abhishek Sharma: Project Fellow & Researcher Scholar, Department of Psychology, Faculty of Social Sciences, Banaras Hindu University, Varanasi-221005, India
Organizational Factors, Fulfilment of the Psychological Contract and
Quality of Patient-Care in Public Hospitals
ABSTRACT
The study examined the impact of hospital organizations’ structure-related factors, namely, decentralization, co-ordination and work autonomy, on perceived levels of psychological contract fulfilment of medical employees and the reported quality of patient care in not-for-profit public hospitals which are (a) attached to a teaching institution, and (b) those which are only involved in providing medical services (railways non-teaching). The study was conducted on a sample of paramedical staff in both types of hospitals (N=200) in northern India through questionnaire method using five-point Likert-type scales. Responses of participants were statistically analyzed through computation of correlation and stepwise regression analysis using SPSS program. Results highlighted the importance of ‘co-ordination’ as the salient structural factor that predicted perceived levels of psychological contract fulfilment and reported levels of quality of patient care in both types of hospitals. Mediator effects of perceived psychological contract fulfilment (PCF) on the relationship between the structural factors and quality of patient care through hierarchical regression analysis revealed that PCF mediated the prediction of quality of patient care by decentralization and work autonomy only in the public (non-teaching) hospital but failed to mediate the prediction of quality of patient care by ‘co-ordination’ in both types of hospitals. Findings highlighted the significance of co-ordination among various specialities and departments in hospitals as the single factor that can be promoted by hospital administrators for increasing perceived contract fulfilment among their paramedical staff and their quality of patient care.
Keywords: Decentralization, co-ordination, work autonomy, psychological contract, quality of patient care.
INTRODUCTION
Despite the fact that HRD often plays an integral role within health care management, little empirical research has explored the relationship between organizational factors, human resource practices in healthcare and quality of patient care in India. As healthcare becomes more complex in terms of the development of new technologies, treatment approaches and financial management systems, the need for efficient staff is increasingly recognized. Added to this are requirements for on-going training leading towards certification and accreditation of both individual employees and hospitals. However, the escalating costs and complexity of health care management have focused little attention on making human resource practices as effective as possible with greater interest in monitoring the results or outcomes. Turnover of health care workers remains an outcome measure of particular interest. The high costs associated with excessive voluntary turnover rates of medical professionals are frequently cited as a key management issue for health care administrators. As health care systems in many nations are experiencing similar issues, the need for empirical studies that examine human resource practices in terms of their implications for the psychological contract and outcomes for healthcare organizations, are increasingly needed.
The concept of the psychological contract was first used by Argyris (1960) and has been developed further by the works of many researchers like Schein (1978; 1980), and most recently by Rousseau (1995; 2000). According to Rousseau (1989) psychological contracts consist of the beliefs employee hold regarding the terms of the informal exchange agreements between themselves and their organizations. The psychological contract is a major variable which generates works effectiveness, commitment, loyalty, and enthusiasm for the organization and its goals. Employer-employee expectations are embedded in psychological contracts, which define the terms of exchange between the employer and employee. Robinson and Rousseau (1994) have suggested that the psychological contract is characterized not only by expectation, but by ‘promissory and reciprocal obligation’. Although these two concepts are seen as related, perceived obligation are seen by Rousseau (1989) as being stronger then expectations. Hence, when these obligations are broken, they produce more emotional and extreme reactions then when weaker expectations are broken. Broken expectations produce feelings of disappointment, anger and a reassessment of the individuals’ relationship with organization.
Earlier Schein (1980) suggested that psychological contracts are key determinants of employees’ attitude and behaviors in the work place. When the parties’ expectations meet each other, performance is likely to be good and satisfaction level high. So long as the values and loyalty persist, trust and commitment will be maintained. But a negative psychological contract can result in employees becoming disenchanted, de-motivated and resentful of authoritarianism within the organization which in turn will result in increasingly inefficient workforce and decreased quality of work. Psychological contract ‘violations’ occur when an employee perceives that the organization has failed to fulfill one or more of its obligations comprising the psychological contracts (Rousseau & Parks, 1993). Morrison and Robinson (1997) defined ‘psychological contract breach’ as the employee’s cognition that the organization has failed to meet one or more of its obligations and psychological contract violation as the emotional or affective state that frequently follows such a perception.
Researchers in this direction have proposed that violation of psychological contracts may be perceived to have two basic causes: reneging and incongruence (Morrison & Robinson, 1997). Reneging occurs when the organization knowingly breaks a promise to the employee, either on purpose or because of unforeseen circumstances. In contrast, incongruence occurs when the employee and the organization have different understandings regarding what the employee has been promised. Guzzo and Noonan (1994) have related human resource (HR) practices with the concept of the psychological contract. They also considered HR management practices as major determinants of employees’ psychological contract and developed a conceptual framework for understanding these relationships. Robinson and Morrison (2000), in discussing causes of contract breach, provided more indications for the relationship between organizational features and psychological contract breach. According to them, when the process of socialization in organizations is fairly formalized or structured in nature, they expect new employees to form a set of beliefs and assumptions that is similar to those held by agents of the organization, which implies congruence and less potential for breach of psychological contract. Eisenberger and Speicher (1992) reported that employees who receive highly valued resources ( e.g., pay raises, development training opportunities ) feel obligated, based on the reciprocity norm, to help the organization reach its objectives through such behaviors as increased in-role and extra-role performance and reduced absenteeism. Coyle-Shapiro and Kessler (2002) presented evidence that fulfilment of the contract had positive effects on employees’ performance. In their study of British civil servants, it was found that employees’ self-reported fulfilment of their obligations, such as working extra hours and volunteering to do non-required tasks, was an increasing function of how well the employees believed the organization had fulfilled its obligations to them.
Turnley and Feldman (2000) suggested that in order to survive major upheavals caused by environmental changes, it is necessary for organizations to understand the conditions which are capable of promoting perception of psychological contract fulfilment among their members. Devidson (2001) examined employee expectations that involve reward for work/effort, safe and comfortable working conditions, opportunities for personal development and career progression, and equitable personnel policies. She concluded that employer expectations involve productivity for reward, working diligently in pursuing organizational objectives and a few other factors. Though Devidson’s model is simplified, it provides a good insight into psychological contract fulfillment. Berman and West (2003) proposed that workload, work schedules, responsibility and authority, quality of work, working relationship with immediate supervisors, interpersonal relations, specific behaviour of employees and managers, individually preferred working styles, job security, rewards, promotion, career development, and loyalty could be part of psychological contract involving employees and employers.
A question that arises for healthcare organizations is: Under what conditions do medical professionals perceive the health care context as favourable or unfavourable? An answer based on the possibility of psychological contract violation can be proposed (Rousseau, 1995). Werner and Asch (2005) argue that by publicly reporting error rates, physicians may compromise their employability and may also expose themselves to malpractice lawsuits. On the other hand, Kohn, Corrigan and Donaldson (1999) suggested that a different possible psychological contract between physicians and their organization is a ‘no-blame’ contract in which both sides agree that errors are because of systemic flaws, which must be detected and corrected. This removes the fear of personal liability and eliminates incentives to hide errors. Hence, one would voice an error to avoid potential hazards and to improve the system. In general, the shared implicit psychological contract in health care organizations is a contract of blame in which an error is believed to be the responsibility of the employee who commits the error(s). Indeed, a recent trend in the health care industry is to use ‘cards’ that publicly report physicians’ success and error rates.
It has often been observed that a ‘no-blame’ psychological contract exists within groups, for example within a team, a ward, or a profession. Ambiguous professional work is executed within the ingroup (Weick, 1979), hence the professionals and the profession perceive an error as an opportunity to learn and develop. However, although the profession supports internal learning and change, it blocks externally-oriented sources of change and learning. This occurs because a psychological contract of ‘blame’ may tend to exist between groups, for example between management or regulators and those who are managed or supervised. As a result, reports will not cross the profession’s borders. For example, physicians tend to be suspicious about external monitoring because ‘they don’t understand our work’ whereas they are ready to conduct fierce internal reviews of failures and to publish them in a different learning format such as Morbidity and Mortality Meetings, and Clinical Pathological Conferences (Ferlie, Fitzgerald, Wood & Hawkins, 2005).
In an earlier series of studies in USA, Karmer and Schmaleberg (1991) investigated the so-called ‘magnet’ hospitals. These institutions have been identified as being successful in recruiting, retaining and motivating nursing staff. The key characteristics of magnet hospitals include participatory and supportive management style, decentralized organizational structure and emphasis on continuing learning. Their study reported that nurses turnover and vacancy rates are low in magnet hospital and job satisfaction is high. In manufacturing organizations success of HR practices may be measured through profit and loss but in healthcare organizations success can only be measured by the quality of patient care delivered. Optimizing the quality of care is imperative for health services worldwide including India. Pledging quality in health care services has become a priority for any health care system. The notion of quality in health services has emerged more strongly because of the rising costs of treatments, constrained resources and evidence of variations in clinical practice (Campbell, Roland, & Buetow, 2000). As there is a lot of awakening in the Indian society about quality services, the responsibility of hospital administration to provide quality services to the community has increased manifold. Quality enters into every aspect of a hospital directly from the time patient is admitted, until the patient is discharged. This implies proper organization and management of hospital system in terms of physical facilities, staff availability of clinical services, equipment, diagnostic and therapeutic services (Goel & Kumar, 2007).
Some authors studying quality management supported the position that successful total quality management (TQM) application is facilitated by high levels of both formalization and decentralization in the organization. Douglas and Judge (2001) found that successful TQM implementation in hospitals is enhanced by a simultaneous use of two seemingly opposing practices: structural control, which implies the use of standard procedures and job descriptions and structural exploration that involve empowerment and freedom to depart from past practices in order to adapt to a changing environment. Similar findings were reported by Germain and Spears (1999). In contrast to the inverse relationship between formalization and quality management that they initially hypothesized, the researchers found a significant and strong positive relationship between these variables and also confirmed a positive effect of decentralization on the quality of product. Meirovich, Brender-Ilan and Meirovich (2007) argued that a paradoxical interaction between formalization and decentralization is related to a similar interaction between the total quality dimensions – quality of design and quality of conformance. The simultaneous need for formalization and decentralization can be explained as means to achieve high levels of both components of quality. Thus poor quality of patient care in hospitals might be rooted in organizational structural characteristics such as degree of formalization, decentralization, co-ordination and work autonomy.
Health services include a wide variety of quality aspect all of which are important. Most scholars in the quality management literature tend to focus on quality definitions. However, it is important to qualify definitions relevant to the sector of activity related with hospitals. Donabedian (1980) highlighted three key quality components:
(1) Inputs/structures – well-trained, multidisciplinary personnel, their motivation towards constant quality improvement, evidence-based and validated standards.
(2) Process – responsiveness to client needs and preferences, support to autonomy and independence, the clients’ right to dignity, client centredness in service planning, client participation, empowerment.
(3) Outcomes – effectiveness of care, continuity of care, client satisfaction, client’s quality of life.
Other researchers such as Øvretveit (2000), refer to other quality dimensions:
(1) Patient quality: whether the service gives patients what they want.
(2) Professional quality: practitioners’ views of whether the service meets patients ‘needs as assessed by professionals (outcome is one measure), and whether personnel correctly select and carry out procedures believed to be necessary to meet patients’ needs (process).
(3) Management quality: the most efficient and productive use of resources to meet client needs, without waste and within limits and directives set by higher authorities.