SPIRITUALITY, MORAL CONVICTION, AND PROSOCIAL RULE-BREAKING IN HEALTHCARE

ABSTRACT

This study investigated the effect of healthcare professionals' workplace spirituality (WPS) on moral conviction and prosocial rule-breaking (PSRB). The data were collected from 315 healthcare professionals from three main districts of South Punjab, Pakistan. We determined the measures' validity using confirmatory factor analysis. We investigated the hypothesized relationships using structural regression modeling. The results demonstrated a significant effect of WPS on PSRB and moral conviction. However, the mediating effect of moral conviction between WPS and PSRB was insignificant. Healthcare professionals may regulate PSRB by screening and promoting individuals with high WPS to positions requiring a high level of PSRB rather than considering health service providers' personal moral beliefs.

KEYWORDS
Workplace spirituality; moral conviction; prosocial rule-breaking; healthcare professionals; ethical dilemma

RESUMO

Este estudo investigou o efeito da espiritualidade no local de trabalho dos profissionais de saúde sobre a convicção moral e quebra de regras pró-sociais. Os dados foram coletados de 315 profissionais de saúde dos três distritos principais de South Punjab, Paquistão. A validade das medidas foi determinada por meio de análise fatorial confirmatória. As relações hipotéticas foram investigadas usando modelagem de regressão estrutural (SEM). Os resultados demonstraram que o efeito da espiritualidade no local de trabalho na quebra de regras pró-sociais e na convicção moral foi significativo. No entanto, o efeito mediador da convicção moral entre espiritualidade no local de trabalho e quebra de regras pró-sociais não foi significativo. Os profissionais de saúde podem regulamentar a quebra de regras pró-sociais, classificando e promovendo os indivíduos com uma elevada espiritualidade no local de trabalho para as posições que exigem alto nível de quebra de regras pró-sociais, em vez de considerar as crenças morais pessoais dos provedores de serviços de saúde.

PALAVRAS-CHAVE
Espiritualidade; convicção moral; quebra de regras pró-sociais; profissionais de saúde; dilema ético

RESUMEN

Este estudio investigó el efecto de la espiritualidad del lugar de trabajo de profesionales de salud sobre la convicción moral y la ruptura de reglas prosociales. Se recolectaron datos de 315 profesionales de salud de tres distritos de Pakistán. La validez de las medidas se determinó mediante el análisis factorial confirmatorio. Las relaciones hipotéticas se investigaron usando modelos de regresión estructural. Los resultados demostraron que el efecto de la espiritualidad en el lugar de trabajo sobre la ruptura de reglas prosociales y la convicción moral fue significativo, aunque el efecto mediador de la convicción moral entre la espiritualidad del lugar de trabajo y la ruptura de reglas prosociales no fue significativo. Los profesionales de salud pueden regular infracciones prosociales mediante el examen y promoción de personas con alta espiritualidad en el lugar de trabajo a puestos que requieran un alto nivel de ruptura prosocial en lugar de considerar creencias morales personales de los proveedores de servicios de salud.

PALABRAS CLAVE
Espiritualidad; convicción moral; prosocial; destrucción de normas; profesionales de salud; dilema ético

INTRODUCTION

In organizational literature, rule-breaking has been studied under the umbrella of deviant behavior and refers to employees' intentional, self-serving violations of formal organizational rules (Morrison, 2006). Most prior studies focused on the destructive aspects of deviant behaviors, such as workplace deviance (Bennett & Robinson, 2000); misbehavior (Vardi & Weitz, 2005); and counterproductive work behavior (Cohen-Charash & Mueller, 2007), which resulted in enormous costs for organizations.

However, employee deviant behavior is not always destructive; it can be constructive, too. To define this kind of constructive deviant behavior, Morrison (2006) coined the term "prosocial rule-breaking" (PSRB) to refer to employees' intentional violation of organizational rules and policies they perceived as hurdles in doing their job in an "effective, responsible, and responsive manner" (p. 9). She argued that unlike other deviant behaviors, which have destructive, negative implications, PSRB is a form of constructive deviant behavior having positive implications for organizations (e.g., efficiency, cooperation, and customer/client retention) (Morrison, 2006).

Despite Morrison's early insight on the usefulness of PSRB for organizations, few researchers (Ambrose, Taylor, & Hess, 2015; Dahling, Chau, Mayer, & Gregory, 2012; Mayer, Caldwell, Ford, Uhl-Bien, & Gresock, 2007; Youli, Xixi, & Xi, 2014) have attempted to uncover its antecedents. Since 64% of participants surveyed by Morrison (2006) recalled engaging in PSRB, more research is needed to understand why some employees engage in PSRB, some do not, and what is/are the underlying mediating mechanism(s) through which different individual and organizational factors lead to PSRB (Dahling et al., 2012; Youli et al., 2014). Addressing this gap, our study aims to make the following contributions:

First, we investigate workplace spirituality (WPS)'s effect on PSRB to address what motivates employees to engage in PSRB. We believe this is the first study investigating employees' WPS as an antecedent of PSRB. Examining this relationship seems plausible because the two important constituents of Ashmos and Duchon (2000)'s definition of WPS (meaningful work and a sense of community) resemble the two antecedents of PSRB, i.e., job meaning and empathy (Morrison, 2006). Second, we investigate moral conviction as an underlying mediating mechanism through which WPS leads to PSRB to examine how this relationship operates. In the workplace, moral conviction means an employee's strong and absolute belief about something being right or wrong, moral or immoral (Skitka & Mullen, 2002). We argue that employees' WPS first develops their moral conviction(s) about aspects of their work life, which then motivates and justifies their engaging in PSRB for the greater good. We address the research calls of Dahling et al. (2012) and Youli et al. (2014) for investigating the mediating factors influencing employees' PSRB by collecting quantitative data gathered through a survey of healthcare professionals.

This study used utilitarianism to support the hypothesized relationship. Considerations of "utility" matter generally in ethics and particularly in health (Emanuel, Schmidt, & Steinmetz, 2018, p. 318). Authors (Holland, 2015; Horner, 2001; Nixon & Forman, 2008; Rothstein, 2004; Royo-Bordonada & Román-Maestre, 2015) agree that healthcare is in essence utilitarian. Utilitarianism provides the healthcare profession an intuitive capacity to preserve the health status and wellbeing of the most individuals. Hence, utilitarianism seems better for determining the actions required for evaluating and justifying morality issues in healthcare. Utilitarianism, as a science of morality for bettering human life, tends to approve or disapprove of actions and regulate the party's happiness whose interest is in question (Bentham, 1789, pp. 6-7). Thus, utilitarianism may also help us explain the spiritual and moral reasons of PSRB behavior/actions of healthcare professionals to examine their effect on patients as interested parties in healthcare.

THEORETICAL FRAMEWORK AND HYPOTHESES

Prosocial rule-breaking

Contrary to rule-breaking, a harmful deviant behavior, PSRB represents the positive side of employee deviant behavior (Morrison, 2006). According to Morrison (2006), "employees do not always break organizational rules/policy for their self-interest, rather sometimes they do it to perform their job in an 'effective, responsible, and responsive manner'" (p. 9). PSRB refers to "any instance where an employee intentionally violates a formal organizational policy, regulation, or prohibition with the primary intention of promoting the welfare of the organization or one of its stakeholders" (Morrison, 2006, p. 6). According to Morrison, employees are generally engaged in PSRB to enhance their efficiency, help their colleagues in job duties, and provide better service to customers. None of these forms of PSRB is a destructive deviant behavior in organizations. In a qualitative investigation, Morrison (2006) found that 64% of respondents had experienced PSRB in their organizations. In an experimental study, she found that support for job autonomy, coworker rule-breaking behavior, and risk-taking propensity showed significant association with PSRB. Thus, Morrison called for researchers to explore these and other factors that might lead employees to PSRB.

However, only three notable studies attempted to address Morrison's call and empirically investigated new antecedents of PSRB. The first was an experimental study (Mayer et al., 2007) finding statistical support for the mediating role of a supervisor's perceived support and moderation of perceived policy fairness between supervisor-subordinate relationship quality and PSRB. The second study was conducted by Dahling et al. (2012), who developed the PSRB scale and found support for the significant correlation of conscientiousness, job demands, and coworker behavior with PSRB. The third study was conducted by Vogel et al. (2014), who found support for the direct and indirect effects of transformational leadership on PSRB through mediation of autonomy.

Thus, in extending the literature on PSRB's antecedents, this study investigates the effect of employees' WPS on their PSRB.

Workplace spirituality

WPS has been conceptualized in many ways with more than 70 definitions (Geigle, 2012). The most common definitions of WPS contain three similar themes (Karakas, 2010; Pawar, 2009): inner life, meaning in work, and a sense of community (Chawla & Guda, 2013; Milliman, Czaplewski, & Ferguson, 2003). We used Ashmos and Duchon (2000)'s definition of WPS, which contains all three themes and refers to WPS as "the recognition that employees have an inner life that nourishes and is nourished by meaningful work that takes place in the context of community" (p. 137). Inner life refers to employees' "spiritual needs [...] just as they have physical, emotional, and cognitive needs. These needs [do not] get left at home when they come to work" (Duchon & Plowman, 2005, p. 811). The second theme, meaning in work, refers to employees' better understanding of their work's purpose and importance in their lives (Ashmos & Duchon, 2000; Duchon & Plowman, 2005). The third theme, a sense of community, refers to employees' shared values, mutual obligations, and commitment to work with the organization's other members as a community (Duchon & Plowman, 2005).

Workplace spirituality and prosocial rule-breaking

During the last few years, WPS has become an emerging area of investigation in organizational research (Ashmos & Duchon, 2000; Chawla & Guda, 2013; Daniel, 2015). Many organizational studies have reported significant effect of employees' WPS on many positive work attitudes and behaviors such as job commitment (Chawla & Guda, 2010), individual well-being (Mackenzie, Rajagopal, Meilbohm, & Lavizzo-Mourey, 2000), work unit performance (Duchon & Plowman, 2005), and organizational performance (Fry & Matherly, 2006). In extending this line of research, we investigate the effect of employees' WPS on their PSRB.

We used utilitarian moral theory to test this relationship in the health sector, as it can be helpful in decisions related to the quality of patients' experiences (Scott, 2007). Utilitarianism is one of the "big three" traditional moral theories developed by Jeremy Bentham (1748-1832), focusing on the overall balance of the positive and negative effects of a healthcare professional's actions (Scott, 2017). Classical utilitarian moral theory explains that human acts or practices are evaluated based on their consequences or utility for others. Although PSRB is a constructive behavior, it involves deviance and risk. However, a recent meta-analytic study (Yonker, Schnabelrauch & DeHaan, 2012) reported risk-taking behavior as a significant psychological outcome of WPS. Moreover, WPS enhances individuals' prosocial motivation. Einolf (2013) found that daily spiritual experiences promote helping behaviors and a sense of others' needs. Godwin, Neck, and D'Intino (2016) propose that spiritual entrepreneurs perceive external business stressors as challenges rather than obstacles. Utilitarian theory suggests socially motivated persons are risk takers who intend to help others by breaking rules in specific conditions (Athanassoulis & Ross, 2010). Based on utilitarian theory, we argued that employees' WPS increased their likelihood of engaging in PSRB. For instance, WPS's inner life dimension makes employees' personal life congruent with their work, which motivates them to fulfill their work efficiently even if it requires breaking organizational rules creating dissonance in their inner life. Their work's higher purpose strengthens their desire to make a difference by taking necessary actions (Spreitzer & Sonenshein, 2003), and a sense of community motivates them toward interpersonal helping behavior by reducing the focus on personal instrumentality (Dahling et al., 2012; Morrison, 2006). Utilitarian theory suggests socially motivated persons are risk takers who intend to help others by breaking rules under specific conditions (Athanassoulis & Ross, 2010). Employees with high WPS are socially motivated people who are generally unafraid of risk-taking to deviate from organizational rules to increase organizational productivity and efficiency (Duchon & Plowman, 2005; Morrison, 2006).

Based on previous arguments and developed through utilitarian moral theory, we hypothesized the following relationship.

H1: Employees' workplace spirituality has a positive association with their prosocial rule-breaking.

To improve understanding of how employees' WPS transmutes to PSRB, it is important to uncover the underlying psychological mechanism creating this relationship. This study incorporated moral conviction as the underlying mediating mechanism through which employees' WPS transmuted to PSRB.

Workplace spirituality and moral conviction

Morality research has gained attention since the last quarter of the 20th century (Skitka, Bauman, & Lytle, 2009). Morality is the notion of correct versus incorrect, and a conviction is a solid belief without the need for evidence (Skitka & Mullen, 2002).

Since development of one's beliefs is a "meaning-making process" (Fowler, 1981), moral conviction can also be regarded as a meaning-making process, particularly to justify actions (Skitka, 2010). The "sense-making" process develops individuals' understanding about their lives, values, and commitments (Fowler, 1981; Cartwright, 2001). According to cognitive development theory, individuals' sense-making processes develop through different stages of incorporating more sophisticated ways of understanding (Cartwright, 2001). WPS should also incorporate more sophisticated ways of understanding toward one's cognitive development or sense-making process. Indication regarding WPS's role in the faith-development process can be obtained from Fowler (1981), who proposed that one's understanding of oneself in relation to others and the centers of shared values and commitment are critical in the sense-making or faith development process (Fowler, 1981). We argue that moral conviction is also a sense-making or faith-development process defined as "a meta-cognitive belief of an individual that a given position is based on one's core moral beliefs and convictions" (Skitka, Washburn & Carsel, 2015, p. 1). Thus, we believe spirituality contributes to one's faith development or sense-making process to justify his moral actions by incorporating a more sophisticated way of understanding as described by cognitive development theory.

One way WPS may incorporate sophisticated ways of understanding in the one's moral attitudes and behaviors is by expanding and deepening his moral conviction (Jackson, 1999). WPS helps stimulate the moral imaginations, e.g., moral convictions, of employees who must deal with ethical issues and leads them to make moral decisions on them (Gull & Doh, 2004). Duchon and Plowman (2005) found that a greater percentage of employees are on a spiritual journey exploring meaning and purpose in their lives during routine job duties (Duchon & Plowman, 2005). We argue that employees' WPS shapes their moral conviction, i.e., their primary values and perceived worldview, about activities, e.g., ethics, morality, helping attitudes, honesty, etc., they experience in the organization's daily life (Godwin et al., 2016).

The relationship between WPS and moral conviction can also be justified using utilitarian moral theory. We have described how WPS influences one's moral imagination/convictions (Gull & Doh, 2004), whereas moral conviction is the belief that one's stance is based on core moral beliefs (Skitka et al. 2015). However, research has shown the reaction of people toward individuals selecting wrong options is a case of ethical dilemma. Utilitarian moral theory indicates that an action's consequences determine if it is right or wrong and moral or immoral. WPS can also be considered a moral act if it develops moral beliefs in individuals. Based on moral theory, we can argue that WPS develops one's moral conviction, or moral conviction is the cognitive belief that is a consequence of WPS. Based on the previous arguments and utilitarian moral theory, we argue that employees with a high level of WPS are very likely to have a high level of moral conviction.

Research has shown the extent that people perceive an ethical dilemma from a moral perspective determines their reactions toward people making wrong choices in situations of ethical dilemmas (Skitka et al., 2015). The reactions of people with high moral convictions are likely to be more moral than in those with low moral convictions. However, WPS influences individuals' moral imaginations/convictions (Gull & Doh, 2004) because moral conviction is a moral belief influenced by WPS. Moral conviction may be seen as a moral consequence of WPS inducing moral reactions. This perspective accords with the utilitarian moral theory indicating an action's consequences determine if it is right or wrong and moral or immoral. Based on these arguments, we hypothesized the following relationship.

H2: Employees' workplace spirituality has a positive association with their moral convictions.

Moral conviction and prosocial rule-breaking

Employees' PSRB is a risk-taking behavior where they must decide whether to follow a particular rule or break it for the sake of better job functioning. This is often not a simple choice; for instance, employees may feel a rule must be violated to optimize their work performance, but may also fear they will be punished (Morrison, 2006). Employees need strong motivation and justification for intended violation(s) of specific rule(s) before engaging in actual PSRB.

When individuals' moral convictions are at stake, they are likely to believe that greater moral purposes dictate rules, procedures, and authority rather than the rules, procedures, or authorities themselves (Skitka, Bauman, & Mullen, 2008; Skitka & Mullen, 2008; see also Kohlberg, 1976; Rest, Narvaez, Thoma, & Bebeau, 2000). Utilitarian theory of moral actions explains actions can be defined as moral if they bring the greatest total well-being (Bartels & Pizzaro, 2011).

We have described that PSRB is a positive form of deviance aiming at benefiting both customer and organization. PSRB can also be described as moral action for the greater well-being. Moral conviction is likely to give employees the courage and motivation they need to help create a better workplace environment (Skitka, 2010). Thus, we argue that employees' moral convictions, shaped by their WPS, not only motivate them to engage in PSRB, but also provide justification for it (Prinz, 2007). Moral conviction research also suggests when people have strong moral convictions and clarity of their work's purpose, they feel released from a tendency to follow standard procedures (Skitka, 2010); consequently, they reject authorities and rules when outcomes violate their moral convictions (Mullen & Nadler, 2008). We have also described that moral convictions provide justification for actions (Skitka, 2010). Since PSRB can be defined as a moral action, individuals with high moral convictions are likely to engage in PSRB. The "side-taking hypothesis" also explains that individuals use their judgment of an action as moral to choose a side in conflicts by focusing on disputants' actions rather than their identities (DeScioli, 2016). Since PSRB is normally required in the same kind of situations representing ethical dilemmas where organizational rules collide with customers' needs, employees are likely to take customers' sides while deviating from organizational rules to enhance their performance (Morrison, 2006).

Based on this argument and research findings, we hypothesized the following relationship.

H3: Employees' high moral convictions have a positive association with prosocial rule-breaking.

Based on the hypothesized direct positive relationships between WPS and moral conviction (i.e., H2) and between moral conviction and PSRB (i.e., H3), we can argue that employees' moral convictions mediate the direct positive relationship between their WPS and the PSRB (i.e., H1). Research suggests that moral conviction, combined with anger, mediates the relationship between unethical business practices and boycotting of consumer goods, e.g., boycotting Walmart products in response to the company not treating its employees well (Skitka, 2010). We argue that employees' WPS first develops their moral conviction, which then leads them to PSRB. Specifically, employees' high moral conviction mediates the direct relationship between their WPS and PSRB.

H4: Employees' high moral convictions mediate the direct positive association between their workplace spirituality and prosocial rule-breaking.

METHODOLOGY

Sample

This study's participants were doctors, pharmacists, drug directors/pharmacists, and clinical psychologists working in 33 districts hospitals. The hospitals were public sector hospitals operating under the Punjab Government Health Department and were located in major districts and tehsils of South Punjab, Pakistan's three divisions. The cities included Multan, Bahawalpur, Deraghazi Khan, Khanewal, Lodhuran, Muzaffargarh, Layyah, Taunsa, and Vehari. Health professionals working in them were monitored and evaluated through a similar set of administrative and human resource policies (like selection, training, compensation appraisal, etc.).

We combined a purposive sampling method with representative sampling to obtain responses from key respondents working in diverse departments and positions in these hospitals. We sought the respondents' consent to participate in the study. The data were obtained from respondents who showed willingness to participate. We obtained three hundred and forty (340) dyadic responses. After removing incomplete responses, three hundred and fifteen (315) valid responses remained.

Design and procedure

This study was quantitative. We collected data through a field survey using paper-and-pencil questionnaires. We began by approaching potential participants working in the hospitals (in cafeterias, wards, and offices during tea breaks). Respondents were also presented a research recommendation letter from the research supervisors on university letterhead and were required to complete a brief questionnaire for a chocolate. Respondents completed the questionnaires during a short face-to-face meeting. The cover letter stated the study's objectives, contained questionnaire guidelines, and ensured confidentiality. Due to the sensitivity of the doctors' job, data collection was difficult in hospital wards. Therefore, data were gathered from respondents in different places (like canteens, wards, and during tea breaks) within the vicinity.

Measures

Moral conviction

We followed Skitka et al. (2005) to measure moral conviction. Skitka et al. (2005) used a single-item scale. However, this measure consisted of a single indicator. It also measured moral conviction in social or political contexts. We did not find a measure of moral conviction in the business context at the time of data collection, so we conducted a pilot study following the procedure of Skitka et al.

In study, we asked respondents to highlight ethical issues they faced while interacting with patients. This informal pilot study revealed many problem areas related to organizational values, bullying, work environment, and work practices (like pay, promotion, etc.), power (abusive supervision), and rule-breaking (nondiscipline/irregularity). Next, we took these issues and developed a multiple-indicator scale based on the scale of Skitka et al. (2005). The item used by Skitka et al. was: "How much are your feelings about ______ connected to your core moral beliefs or convictions?" We completed blank spaces with each of the problems respondents reported during the pilot study and constructed a scale using eight different items.

The moral conviction scale's sample items included: "How much are your feelings about power (abusive supervision) connected to your core moral beliefs or convictions?"; "How much are your feelings about organizational values connected to your core moral beliefs or convictions?"; and "How much are your feelings about rule-breaking (nondiscipline/irregularity) connected to your core moral beliefs or convictions?" We asked participants to respond on a 5-point radio-button scale with "1 = not at all" and "5 = very much." The scale's overall reliability was 0.80.

Respondents reported against each statement. After collecting data, we performed reliability and validity tests. Four different items of moral conviction remained in the final CFA model.

Workplace spirituality

We assessed WPS using the work scale developed by Ashmos & Duchon (2000), containing three subscales and 21 items. The subscales' reliability was 0.82 for community, 0.78 for meaning at work, and 0.77 for inner life. The overall Cronbach's alpha was 0.89. We gathered all responses on a 5-point Likert-style scale ranging from "strongly disagree = 5" to "strongly agree = 1." Sample items included: "I feel part of a community in my immediate workplace (hospital, ward, etc.);" "I experience joy in my work;" and "I feel hopeful about life."

Prosocial rule-breaking

We measured PSRB using 13 items developed by Dahling et al. (2012). We obtained responses to this variable from respondents' colleagues for accurate results. The scale's overall reliability was 0.90. We used a frequency-type anchor ranging from "never = 1" to "always = 5" to collect responses. The scale's sample item was: "This employee has broken rules that stand in the way of good patient care service."

Control variables

Since the tendency toward risk-taking is lower in women (Morrison, 2006), there could be significant difference in PSRB in male and female respondents. Harrison (2015) reported gender as a significant predictor of PSRB. Curtis (2010), and Curtis, Upchurch, and Dickson (2013) found significant difference in a restaurant's frontline employees' PSRB behavior regarding age, experience, and job designation. Youli et al. (2014) found job position significantly affected the PSRB behavior of employees working in different Chinese organizations. Similarly, Skitka et al. (2005) emphasized knowing participants' age, gender, experience, and job nature were important for internal validity of PSRB because respondents' demographic characteristics could possibly significantly affect PSRB. We controlled for the possible effect of respondents' characteristics, including gender, age, experience, and job description as dependent variables. We provide the respondents' demographic details in Table 1.

Table 1
Demographics of research participants

Variables	Categories	Percent
Gender	Male	57.8
	Female	42.2
Age	25-34	60.3
	35-44	24.1
	45-54	9.5
	55-64	6.0
Education	MBBS	49.8
	MBBS, FCPS	30.5
	MBBS, MCPS	15.2
	MD	1.6
	BDS	1.3
	B PHARMACY	1.6
Nature of job	Permanent	80.3
	Contract	18.1
	Part time	1.6
Experience (in years)	1-5 years	54.0
	6-10	20.6
	11-15	14.0
	16-20	5.1
	21-25	1.6
	26-30	1.0
	31-35	3.8
Designations	MO/WMO/Demonstrator	31.1
	PGR/PGMO/FCPS Trainee	19.7
	Pharmacists/Drug Directors	1.6
	Senior Registrars/HODs/Superintendents	14.0
	Assistant Professors	7.0
	House Officers/Psychologists	21.0
	Surgeons/Dental Surgeons	5.7
Total		100

RESULTS

Analytical procedure

The data analysis procedure commenced with preliminary screening and testing of basic assumptions, including normality, outliers, multicollinearity, etc. We provide statistical estimates for mean, standard deviation, and correlations among independent, dependent, mediating, and control variables in Table 2.

Table 2
Means, standard deviations (SD), and correlations

	Mean	SD	1	2	3	4	5	6	7
1. Gender	-	-	1
2. Education	-	-	-0.045	1
3. Job nature	-	-	0.008	-0.272**	1
4. Position	-	-	0.06	0.081	0.583**	1
5. Experience	-	-	-0.082	0.364**	-0.310**	0.084	1
6. WS	4.25	0.467	-0.135**	0.108**	0.133	0.225	0.141**	1
7. MC	3.52	0.806	-0.167*	0.090	0.053	0.120	0.199**	0.370**	1
8. PSRB	2.86	0.818	-0.077*	-0.055*	0.030	-0.071	-0.075	0.095*	-0.004

• ^*
  Correlation is significant at the 0.05 level (2-tailed).
• ^**
  Correlation is significant at the 0.01 level (2-tailed).
• WS = Workplace Spirituality
  MC = Moral Conviction
  PSRB = Prosocial Rule-breaking

Confirmatory factor analysis (CFA) (Tabachnick and Fidell, 1996; Tabachnick and Fidell, 2007) was one of the methods used to determine convergent and discriminant validity of measures (Harrington, 2009). We performed CFA to examine model fit and determine convergent and discriminant validity of variables. We performed CFA using the maximum likelihood estimation and variance-covariance methods. We used Brown's (2015) criteria to determine model fit (Harrington, 2009). The model indices included absolute fit indices (χ2/df and RMR), parsimony correction indices, i.e., root mean square error of approximation (RMSEA), and comparative fit indices (CFI, GFI, and IFI). A reasonable model fit required that the ratio of the chi-square to the degree of freedom (χ2/df) be less than three, the CFI values greater than or equal to 0.95, and the values of RMR and RMSEA close to or less than 0.05 (Hu & Bentler, 1999; Kline, 2011; Harrington, 2009).

Since WPS and PSRB were multidimensional construct, we introduced them as second order latent factors in the CFA model. However, we introduced moral conviction as a first order construct. The initial model fit was inadequate (chi-square/DF = 2377.864/851; CMIN/DF = 2.794; RMR = 0.091; CFI = 0.754; TLI = .739; IFI = 0.756; GFI = 0.751; RMSEA = 0.073). We drew one covariance between items 4 and 5 of the moral conviction and two covariances between items 6 and 7 and between items 6 and 9 of employee PSRB dimension. The final CFA model demonstrated reasonable model fit (chi-square/DF = 543.796/218; CMIN/DF = 2.494; RMR = 0.079; CFI = 0.90; GFI = 0.876; IFI = 0.90; RMSEA = 0.069).

We followed Fornell and Larcker (1981)'s recommendations and used CFA results to determine the constructs' convergent and discriminant validity. A measure's convergent validity is established if the average variance extracted (AVE) is less than the composite reliability but equal to or greater than 0.50. Discriminant validity is established if the AVE is greater than the maximum shared squared variance (MSV) or average shared squared variance (ASV). We used a statistical tools package developed by James Gaskin (http://statwiki.kolobkreations.com/index.php?title=Main_Page) and correlations and standardized regression coefficients from the full CFA model to determine convergent and discriminant validity. This package automatically calculated the values of CR, AVE, ASV, and MSV along with the measures' correlations. The results in Table 3, which follow, showed that the conditions of convergent and discriminant validity of the measures used in this study's model were satisfied. The ratio of chi-square to degrees of freedom was less than 3, representing discriminant validity (Carmines & McIver, 1981).

Table 3
Estimates of convergent and discriminant validity and composite reliability

	CR	AVE	MSV	Reliability
Moral Conviction	0.800	0.512	0.164	0.878
Workplace Spirituality	0.894	0.738	0.164	0.945
Prosocial Rule-Breaking	0.853	0.666	0.023	0.967

• CR = Composite Reliability
  AVE = Average Variance Extracted
  MSV = Maximum Shared Variance

Table 4
Statistical results of mediation analysis using 2000 bootstrapping samples with 95% confidence interval

Variables	Model 1 DV = PSRB	Model 2 DV = MC	DV = PSRB
Gender	-0.071(0.119)	---	-0.072(0.119)
Education	-0.042(0.093)	---	-0.041(0.055)
Experience	-0.032(0.043)	---	-0.032(0.043)
Designation	-0.030(0.012)		0.030(0.012)
Direct Effects
Workplace Spirituality	0.143(0.169)*	.421(.152)***	0.147(0.192)
Moral Conviction (MC)	---	---	-0.021(0.089)
Indirect Effect: WPS🡢MC🡢 PSRB	---	---	β= -0.009 95% confidence interval with 2000 bootstrapping samples = [upper bound = 0.060, lower bound = -0.115]

• ^*
  Relationship is significant at the 0.05 level (2-tailed).
• ** Relationship is significant at the 0.01 level (2-tailed).
• PSRB = Prosoial Rule Breaking
  Note: Beta coefficients, standard error (in brackets) and p-values (as asterisks) are reported.

We also assessed common method variance through different procedural and statistical manipulations based on Podsakoff, MacKenzie and Podsakoff (2012)'s recommendation. First, the scale anchors measuring each construct were different. Second, multisource data used to rate PSRB were obtained from the respondents' colleagues. Third, we conducted Herman single-factor analysis (Podsakoff & Organ, 1986) using exploratory factor analysis in SPSS, where we restricted all items to load on a single factor. This single factor explained the 18% variance only, which was below the threshold level (40%) described by Podsakoff et al. (2012). We performed CFA by adding a common latent factor connecting all the instrument's items. We restricted all paths between the common latent factor and all observed variables to be equal to 1. This CFA model explained the 4% variance in all latent factors. Both tests demonstrated that common method variance was not an issue in our study.

Hypotheses testing and mediation analysis

We examined the hypothesized relationships using structural equation modeling (SEM) in AMOS. We performed mediation analysis with the bootstrapping method recommended by Cheung and Lau (2017) and MacKinnon, Coxe & Baraldi (2012). We preferred SEM because testing structural regression models of indirect effect with bootstrap was better than testing hierarchical multiple regression and then performing a Sobel test to analyze the mediation. First, we tested a structural regression model to examine moral conviction's effect on PSRB (chi-square/DF = 499.875/246; CMIN/DF = 2.032; RMR = 0.03; CFI = 0.922; IFI = 0.924; RMSEA = 0.057 PClose = .048). Statistical results demonstrated the direct effect of WPS on PSRB was positive and significant (β = 0.143, p < 0.05). These results supported the study's H1. We tested another structural regression model, examining the indirect effect of moral conviction on PSRB through WPS using 2,000 bootstrap samples and 95% bias-corrected and accelerated confidence intervals. The structural model demonstrated adequate fit (chi-square/DF = 650.073/323; CMIN/DF = 2.013; RMR = 0.091; CFI = 0.91; IFI =.91; RMSEA = 0.057). This study's statistical result demonstrated that WPS was positively associated with moral conviction (β = 0.421, p < 0.001), supporting H2. Further, moral conviction's effect on PSRB was negative and insignificant (β = -0.021, p > 0.05). Hypothesis 3 was not supported. We found moral conviction's direct effect on PSRB in the mediation model was positive and insignificant (β = 0.147, p > 0.05). Moral conviction's standardized indirect effect on PSRB through WPS was negative but insignificant (β = -0.009, p > .05), and the upper and lower bounds of a 95% confidence interval included zero [0.060, -0.110]. These statistical results did not support hypothesis 4, which stated that moral conviction mediated the relationship between WPS and PSRB.

DISCUSSION

Healthcare relies on high contact between service providers and receivers, where service experience depends upon service quality (Groth & Grandey, 2012) and employees are vital to the service experience of a customer, i.e., a patient (Bowen & Ford, 2004; Hartline & Ferrell, 1996; Kelly, 1992). The service quality provided by healthcare professionals is critical. Berry, Carbone, and Haeckel (2002) divided service experience into three categories: functional clues, mechanic clues, and humanic clues. Employee behavior falls into the humanic clues category (Wall & Berry, 2007). We can categorize PSRB behavior of healthcare professionals into the human clues category. Understanding PSRB's role in customer (patient) experience is important for developing high service quality in the healthcare profession.

Research shows moral conviction has been reported as a significant predictor of attitudes and behavioral forms of interpersonal intolerance toward others (Cole Wright, Cullum, & Schwab, 2008). As a form of constructive deviance, PSRB also includes some kind of interpersonal intolerance. Investigating the role of the healthcare professional's moral conviction in PSRB was critical in enhancing customer experience and service quality. Although we found the relationship between moral conviction and PSRB insignificant in this study, it was vital to test it.

We used the utilitarian theory of moral action to predict this study's hypotheses. Utilitarian theory explains that socially motivated persons are risk takers who intend to help others by breaking rules in specific conditions (Athanassoulis & Ross, 2010). The significant and positive relationship we found between WPS and healthcare professionals' PSRB supported this perspective. This implied that HR professionals should consider WPS an important factor when hiring healthcare professionals for positions requiring high PSRB. Researchers (Shepherd et al., 2017) have stressed emphasizing spiritual growth to caregiving professionals because it might affect their care. WPS becomes critical for healthcare professionals and they can use screening mechanisms to identify individuals with high levels. Similarly, the relationship between WPS and moral conviction also emphasizes the need for healthcare professionals to train employees to enhance their WPS because it strengthens their moral convictions. WPS can be an important tool for developing moral convictions, depending on organizational requirements.

We used the utilitarian theory of moral action to predict the relationship between moral conviction and PSRB. People with strong moral convictions tend to defy authorities, rules, or laws more (Skitka, 2012) because they provide motivation (Skitka, 2010) and inherent justification (Prinz, 2007) for PSRB. We expected that moral conviction would be associated with PSRB. However, we found that moral conviction was not a significant predictor of PSRB. Although PSRB was a constructive behavior, it involved certain risk. PSRB required a significant motivational source, and mere moral conviction did not lead to PSRB. In healthcare organizations where doctors face ethical dilemmas, patients might be highly likely to drive PSRB.

Skitka (2012) indicated that people's moral conviction must enhance their moral courage to defy the pressures of formal authorities or group norms on an issue. The authority independence hypothesis explains that people become less concerned with the cost of defying authorities or the law when they have a personal moral stake in a situation. One can argue that moral conviction may not predict PSRB in healthcare professionals, as it is risky, if it does not induce moral courage. Moral conviction may have an indirect effect on PSRB through moral courage rather than a direct one. Future researchers can test the relationship between moral conviction and PSRB using moral courage as a possible mediator.

Similar to our third hypothesis, we also expected that employees' WPS first developed their moral conviction, which then led them to PSRB. We did not find statistical support for the hypothesis stating that employees' high moral conviction mediated the direct positive association between their WPS and PSRB.

Such findings demonstrated that employees' WPS positively affected their moral conviction. However, moral conviction did not lead employees toward PSRB. Employees' WPS would enhance their moral conviction, but they would not engage in PSRB based on this. Based on the arguments previously described by Skitka (2012), one can argue that, instead of moral conviction, moral courage can mediate the relationship between WPS and PSRB.

CONCLUSION

Spirituality plays a more significant role in determining healthcare professionals' PSRB behavior than their personal moral convictions. Based on utilitarianism, we examined how moral conviction might mediate the relationship between WPS and PSRB in healthcare professionals. We did not find statistical support for the hypothesized mediating role of moral conviction between WPS and PSRB, yet we believe our study will stimulate research to identify the mechanisms through which spirituality may strengthen PSRB in healthcare professionals.

Limitations and Future Research

This study had limitations that can be addressed in future research. We found the effect of moral conviction on PSRB was significant. However, based on Skitka (2012)'s arguments, we stated that moral conviction might affect PSRB through moral courage. Future research can be conducted by investigating moral courage's mediating role between moral conviction and PSRB. Future research can also be conducted to examine the effect of WPS on PSRB through moral conviction and moral courage using either serial or parallel mediation mechanisms. These models may be extended further to investigate PSRB's effect on service quality provided by healthcare professionals to patients. This study introduced PSRB as a dependent variable and multidimensional construct consisting of three different dimensions. Moral conviction's effect on PSRB might differ with respect to the dimensions of PSRB. Future research can be conducted by investigating the direct and indirect effect of WPS on each dimension of PSRB separately.

Practical Implications

Our findings have managerial implications. Healthcare managers enjoy discretion of hiring healthcare professionals who enhance customer experience and service quality. However, healthcare professionals also face ethical dilemmas and may require violating existing organizational policies to enhance customer experience. PSRB emerges as a positive form of deviance to do so. Healthcare managers may be interested in recruiting professionals based on certain factors indicating a high tendency for PSRB. We showed that spirituality was positively associated with constructive deviance behaviors within employees, like PSRB. The positive association between WPS and moral conviction means that a spiritually rich workplace can shape employees' moral convictions. This offers one of the study's most important implications for healthcare managers. Since an organization's required level of PSRB may differ by position (Curtis, 2010), organizational managers can encourage recruitment and promotion of employees with high levels of WPS to positions requiring high levels of PSRB. They can use screening tests to identify people with high WPS during recruitment.

The insignificant relationship between moral conviction and PSRB implies that one's belief system is not what encourages deviant behaviors, even if PSRB is a form of constructive deviance. Perhaps customer requirements, ethical dilemmas, or individuals' moral courage encourage PSRB. An employee's deviant behavior may not be predicted based on moral convictions. The insignificant mediating role of moral conviction between WPS and PSRB offers interesting implications for healthcare professionals. Specifically, they can emphasize training people in WPS and focus less on individual specific moral beliefs' role in regulating employee PSRB.

• Translated version

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Edited by

Evaluated through a double-blind review process. Scientific Editor: Maurício Serafim

Publication Dates

• Publication in this collection
  Jan-Feb 2019

History

• Received
  11 Aug 2017
• Accepted
  18 July 2018