A moderated-mediation model of the relationship between responsible leadership, citizenship behavior and patient satisfaction

Zeba Khanam (Department of Commerce, Aligarh Muslim University, Aligarh, India)
Sheema Tarab (Aligarh Muslim University, Aligarh, India)

IIM Ranchi Journal of Management Studies

ISSN: 2754-0138

Article publication date: 13 December 2022




Based on the theory of planned behavior (TPB) and stakeholder theory, the model proposes that responsible leadership (RL) is mediated by affective commitment (AC) on both outcome variables (organizational citizenship behavior [OCB] and patient satisfaction [PS]) while distributive justice (DJ) moderates the relationship among RL, OCB and PS through the mediator of AC.


Overall, data collected from 275 employees and patients in India’s healthcare sector support this model both in online and offline mode. SPSS 25, AMOS 22 and PROCESS macro were used to analyze the data.


The influence of RL, OCB and PS was seen insignificant in the Indian healthcare sector. This study examines the role of AC as a mediator which does not affect extra-role behavior and PS. The findings also show that the moderation-mediation effect of DJ through AC strengthened the link between RL and OCB, but not PS. Commitment does not affect extra-role behavior and PS.


Until now, there has been no research in the Indian context that has tested the effect of RL on extra-role behaviors and PS, as mediated by AC, according to researchers’ knowledge. Since RL and outcome variables are related through AC, the current study aims to understand how DJ acts as a moderator to that relationship.



Khanam, Z. and Tarab, S. (2022), "A moderated-mediation model of the relationship between responsible leadership, citizenship behavior and patient satisfaction", IIM Ranchi Journal of Management Studies, Vol. ahead-of-print No. ahead-of-print. https://doi.org/10.1108/IRJMS-07-2022-0076



Emerald Publishing Limited

Copyright © 2022, Zeba Khanam and Sheema Tarab


Published in IIM Ranchi Journal of Management Studies. Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence may be seen at http://creativecommons.org/licences/by/4.0/legalcode

1. Introduction

The health sector is a complicated one, and in order to give patients the high standard of care, it is necessary for many specialists to work together. In India’s healthcare system, there is a real shortage of trained medical professionals, including doctors and paramedical staff members like nurses and lab technicians. Different workers with varied disciplines who provide healthcare to a patient could make mistakes that might result in risking the patient’s safety and substandard service delivery (Ash, Berg, & Coiera, 2004). The way an individual is treated, given a diagnosis and followed up on has an impact on whether or not the individual’s well-being and standards are maintained. Failure to adhere to evidence-based regulations at any of the above steps can result in inadequate healthcare and put patients’ safety at risk (Deng et al., 2009). A patient’s satisfaction is a balancing act between both the expectation and perception of the quality of nursing care. It is the sense of care received vs intended. The major factor for this is that in current modern health sector, providing individuals with the best possible treatment is crucial. Understanding the patient’s perspective can help healthcare providers deliver better care and boost patient satisfaction (PS) in the face of the industry’s increasing competition (Ng & Luk, 2019). According to a recent study, transformational leadership is essential for retaining nursing staff and increasing PS in general. The quality of patient care is enhanced when the nursing staff is happy (Robbins & Davidhizar, 2020). Patient experience surveys will help healthcare practitioners determine whether they are meeting or falling short of their patients’ expectations in any realm. Responsible leadership (RL) is an ethical and social framework wherein different management leaders inspire, export and distribute the values of knowledge, courage and respect to diverse stakeholders (Hymavathi, Kasarabada, & Avadhanam, 2015). This is a people-centered activity whose main goals are to aggregate society’s welfare, improve the environment’s well-being, provide better service to society and ensure social harmony values in the societies where the organization works. The issue of responsibility is highlighted by leadership theory. Existing leadership styles such as authentic, charismatic, participatory, transformational, shared, servant, spiritual and ethical, according to Waldman and Galvin (2008), lack the concept of responsibility. Similarly, there are increasing pressures on corporate executives to operate their companies responsibly while also considering the needs of society and the environment. The concept of RL (Maak & Pless, 2006) is defined as follows: “RL is the art of building and sustaining good relationships with all relevant stakeholders.” In addition to showing by example how to make decisions correctly, responsible leaders show their followers that they care about them (Zhao & Zhou, 2019). Employee performance in extra-role behaviors, such as organizational citizenship behavior (OCB), can be improved through RL. It strives to make decisions that consider the interests of all parties, including those of stakeholders inside and outside the organization (Han, Wang, & Yan, 2019a, b). Recent empirical studies on RL have been published in the healthcare sector (Mousa, 2018; Mousa & Puhakka, 2019). Additionally, there is a lack of existing literature on the perspectives of RL, distributive justice (DJ), affective commitment (AC), OCB and individual satisfaction in the Indian health sector.

AC is what happens when a worker genuinely wants to be dedicated to a particular objective. When employees and managers get along well, they feel more compelled to support change initiatives. A person who makes a rational choice to protect his/her job and the compensation, recognition and other benefits that come with it is said to have an AC (Haim, 2007). This could be the key to a long-term, sustainable healthcare reform. Issues of DJ influence individuals’ lives, especially the lives of organizations and groups. DJ is highly valued by employees because of the general perception that people are concerned to equity issues (Adams, 1965; Greenberg, 1989), which also encourages people to further attention and detail in their explanations of how the results are distributed (Beugré and Baron, 2001). In simple terms, scholars who believe in the merits of organizational justice are of the opinion that workers to a great extent have optimistic attitudes toward their jobs, the results of their jobs and their managers if they believe they are being treated fairly in the workplace (Moorman, 1991).

Therefore, using the moderated-mediation model, researchers seek to comprehend how RL, OCB and PS are related. As a result, this study will consider the following research questions:


What is the influence of RL and OCB?


What is the influence of RL and PS?


What is the mediating role of AC between the relationship of RL and OCB?


What is the mediating role of AC between the relationship of RL and PS?


What is the moderating role of DJ through AC between the relationship of RL and OCB?


What is the moderating role of DJ through AC between the relationship of RL and PS?

2. Theoretical background and hypothesis development

2.1 Responsible leadership and organizational citizenship behavior

Establishing a long-term relationship with stakeholders as well as with the community, the environment and future generations is how RL combines leadership and social responsibility. Traditional leadership focuses on its influence on employees, whereas RL takes into account relationships with a variety of stakeholders. This is the fundamental distinction between the two types of leadership. “It is a relative and moralistic process that causes in social processes of interaction with individuals who impact or impacted by leadership and have a share in the leadership association's goals and perception” (Maak & Pless, 2006). The literature on organizational studies is leaning more and more toward proactive and responsible behavior. From the standpoint of the organization, a responsible leader makes sure that workforce rules are enforced (both internationally and within the supply chain), that working conditions are humane, secure and free of discrimination, and that workers’ needs for relaxation, work–life balance and work engagement are fulfilled (Maak & Pless, 2006). RL links leader effectiveness, stakeholder approval and employee engagement in the organization and society. Empathy, positive affect and universal values foster RL (Voegtlin, Frisch, Walther & Schwab, 2020).

Scholarly discussion of RL is becoming more important as demands for transparency and accountability increase. Leaders’ responses to the dual responsibility of preventing or minimizing harm to stakeholders while maximizing accomplishing good for them demonstrate the ethical component of RL behavior (Longest, 2017). RL encourages employee attachment towards leader and the organization, which enhances organizational commitment and reduces the negative impact on employees’ turnover intentions (Han et al., 2019a, b). Additionally, ethical leaders value their followers’ perspectives on social responsibility initiatives, suggesting that a leader can enhance how the staff perceives the importance of this kind of work for the good of the company and society (Freire & Gonç Alves, 2021). OCB is one such beneficial result that aids a company in creating a friendly workplace environment. It is a commendable behavior that explains why employees voluntarily go above and beyond what is required to help organizations deal with the unprecedented situation (Appelbaum et al., 2004). Sustainable actions are also correlated with citizenship behavior. The power of RL as a strong antecedent to OCB has been the subject of numerous studies (Voegtlin et al., 2020; Elche et al., 2020), and employers should encourage their staff to adopt eco-friendly practices by promoting OCB values (Boiral et al., 2021; Robertson & Barling, 2013; Thakur & Sharma, 2019). A slight variation in the dimensions of civic virtue in the OCB, consciousness and helping others is explained by RL. Through instilling a sense of personal accountability for making positive change, the case study conducted in the Chinese context documents an indirect impact of RL on OCBE (Han et al., 2019a, b). Empirical findings from a Chinese case study of chain hotel employees confirmed that RL was positively related to OCBE and that leader identification mediated the relationship (Zhao & Zhou, 2019). Additionally, the direct and indirect links between RL, subordinates’ moral identity and OCBE were stronger when individualism was lower (Xiao, Zhou, Yang, & Qi, 2021). The theory of planned behavior (TPB) further helps us in understanding the relationship between RL and OCB argued in our study because a leader’s decisions have the greatest impact on their team members (Doh & Stumpf, 2005). When and why a follower respects the leader and his/her organization would be explained by the concept of planned behavior in a leadership environment. The underlying premise of the theory is that an individual’s intentions determine their actions, which are affected by their attitude, subjective norms and perceived behavioral control (Ajzen, 1991). Therefore, as suggested by literature and guided by TPB, we hypothesize the following argument:


RL is positively related to OCB.

2.2 Responsible leadership and patient satisfaction

PS is a significant and prevalent metric for assessing the standards of healthcare. New nursing approaches will allow managers to give each nursing unit the freedom to use independent and creative thinking to improve patient care and staff involvement (Robbins & Davidhizar, 2020). Clinical outcomes and individual satisfaction have an effect on patient retention and medical malpractice lawsuits. It has an effect on the timely, effective and patient-centered transfer of high-standard healthcare. PS is defined as a person’s “personal appraisal of healthcare services and providers,” according to Larson, Rovers, and MacKeigan (2002). Regarded as satisfaction determinants are the patient’s preferences and expectations, while care components are the technical and interpersonal aspects of care (Larson et al., 2002). Additionally, a good leader makes an effort to ensure the security of their patients. Responsible leaders take precautions to ensure that their goods and services meet the requirements of their clients and other stakeholders, that they are risk-free and nontoxic (i.e. do not contain asbestos) and that any potential or actual dangers are communicated in a manner that is both clear and accurate (Maak & Pless, 2006). An accountable leader can inspire followers by acting responsibly with all stakeholders using stakeholder theory. According to the stakeholder theory, organizations are responsible for the production of externalities, which can result in stakeholders exerting pressure on businesses to reduce the negative effects they have and, as a result, influence the behavior of organizations (Sarkis, Zhu, & Lai, 2011; Chavez, Yu, Feng, & Wiengarten, 2016). Business leaders must engage in stakeholder theory in a consistent and determined manner. Stakeholder theory principles can lead to a more engaged workforce and higher returns on corporate social responsibility activities for your organization. According to the literature, primary stakeholders are those who are directly impacted by the organization operations and are critical to its life span (e.g. customers, suppliers and government), whereas secondary stakeholders are those who affected by the organization but no direct impacted by its operations or critical to its survival (e.g. nongovernmental firms) (González-Benito & González-Benito, 2006). According to this study, there was no significant association between leadership style (from the perspective of the nurses) and individual satisfaction with the health services given in an Iranian teaching hospital. Further, it is recommended that to achieve greater efficiency, hospitals and healthcare providers implement reasonable principles and standards, such as rewarding health workers for their actions, conducting regular performance evaluations of head nurses, involving them in decision-making processes and encouraging them to use their managerial creativity and innovation (Bahadori, Peyrovi, Ashghali-Farahani, Hajibabaee, & Haghani, 2018). To empirically examine the efficacy of participative leadership as a leadership style for measuring PS, a case study of a hospital in Pakistan was used. According to the findings, a service delivery system must prioritize administrative and medical standards in order to maximize PS (Asif, Jameel, Hussain, Hwang, & Sahito, 2019a). Transformational leadership has thus gained more attention in the field of general healthcare and nursing in particular because it encourages work happiness and enhances flexibility and organizational commitment and prosperity in workers. As a result, patients are more satisfied (Asif et al., 2019b). As per recent research, the leadership styles of healthcare managers and other professionals have a direct impact on how well hospitals manage their hotel services’ quality. It was discovered that hospital and hotel services played a role as a mediator in the association between leadership styles, PS and total quality management (Turgutogullari & Saner, 2021). Moreover, this study revealed how nurse managers can support high-quality services by assessing PS with nursing care to develop and improve care (Karaca & Durna, 2019). Multiple studies have been done for different leadership styles and PS in the past literature but no study has investigated the association between RL and PS in any manner. As a result, the second hypothesis is evolved in order to examine the relationship between RL and PS.


RL is positively related to PS.

2.3 The mediating influence of affective commitment on the relationship between responsible leadership and organizational citizenship behavior

AC is the important aspect to enhance the employee emotional attachment with their organization. Leaders can enhance the employee emotional attachment to their organization (Avolio, Gardner, Walumbwa, Luthans, & May, 2004). Employees’ OCB is a direct result of their emotional attachment to the organization. Cropanzano and Mitchell (2005) and Ng and Feldman (2011) pointed out that employees will actively execute extra-role behavior when they develop emotional attachment to the organization. Ribeiro, Duarte, Filipe, and David (2021) are identify in their study followers feel more strongly connected to their organization when they see certain attributes in leaders, such as self-awareness, relational transparency, an internal moral perspective and balanced information management. Positive interactions among leaders and employees can boost employees’ feelings of belonging and recognition with the firm (Wang, Qin, & Zhou, 2021). Employees’ AC to the organization will be strengthened, having a significant impact on their work attitudes and behavior (Tayfur Ekmekci et al., 2021). Numerous studies have demonstrated that employing AC frequently yields favorable results. Additionally, AC plays a significant role in how well employees perform their job duties and behave as organizational citizens (Gupta, Agarwal, & Khatri, 2021), creativity and innovative behavior (Zhu & Wang, 2019). A recent study found that AC among nursing staff in long-term care facilities mediated the relationship between nursing climate and government ratings of quality of care (Woznyj, Heggestad, Kennerly, & Yap, 2019). Moreover, the case study of Pakistani employee’s mediation analyses depicts that all variables, that is, AC, intrinsic and extrinsic job satisfaction, partially mediate the association between employees’ CSR perception and OCB (Khaskheli et al., 2020). Employees who have a low level of AC, on the other hand, lack a sense of purpose and belonging to the company, are generally unenthusiastic about their jobs and are less likely to take the initiative to engage in extra-role behaviors.


AC mediates the positive relationship between RL and OCB.

2.4 The mediating influence of affective commitment on the relationship between responsible leadership and patient satisfaction

In previous research, the mediating role of AC in the association among RL and PS has never been investigated. However, only a small number of studies have provided empirical evidence to support the idea that AC can serve as a mediator between factors like quit intention and RL (Haque, Fernando, & Caputi, 2019). In the area of healthcare in general, and nursing in particular, transformational leadership style has drawn more attention, according to Asif et al. (2019b), because it increases organizational commitment and employee welfare while also improving job satisfaction and facilitating change processes, all of which ultimately improve PS. The current study thus proposed that AC mediates the relationship between RL and PS.


AC mediates the positive relationship between RL and PS.

2.5 The moderating role of distributive justice

Positive organizational behavior among employees not only promotes the organization’s objectives but also improves individual and organizational performance. Organizational justice is a key notion in organizational research because it is thought to be a broadly accepted indicator of employee and organizational outcomes (Pan, Chen, Hao, & Bi, 2018). DJ, procedural justice, interpersonal justice and informational justice are the four dimensions of organizational justice (Colquitt, 2001). The theory of equity that supports the concept of DJ is completely influenced by its Adams (1965). In order to understand how salary, rewards and compensation are proportionately and fairly distributed among employees in an organization, it is vital to understand DJ (Le and Lei, 2017). Consequently, when receiving satisfactory or positive outcomes, employees are less concerned with the characteristics and motivations of their leaders. In other words, it is assumed that everything, including management and supervision, is progressing well if organizational outcomes are positive (Greenberg, 2004; De Cremer et al., 2004).

Conversely, if the outcomes are viewed as unfair, this can have a negative impact on positive organizational outcomes, like work engagement. Low perceptions of fairness may also lead to employees quitting their jobs. Numerous studies have confirmed that DJ improves organizational and employee performance and reduces negative work behavior (Le & Nguyen, 2022; Cenkci & Otken, 2019; De Cremer et al., 2004). A case study of fashion chain stores in China and Hong Kong examined the relationship between emotional exhaustion and job performance, as well as the moderating effects of DJ and positive affect. Janssen, Lam, and Huang (2010) DJ has been studied in the present context as a moderator between RL through AC and two outcome variables (OCB; PS) in the Indian healthcare sector. Recent studies confirm that employees’ perceptions of career development opportunities within their organizations have a significant impact on the relationship between transformational leadership and organizational commitment through procedural justice as a moderator (Bashir, Haider, Asadullah, Ahmed, & Sajjad, 2020). Furthermore, a case study of nurses employed by a public hospital in Malaysia demonstrates that DJ has significantly moderated the relationship between two components of the TPB (attitude and subjective norm) and knowledge sharing (Samadi, 2018). The study discussed the improper allocation of resources (DJ) and the conflict between nurses’ and midwives’ duty of care and resource allocation in Kenya during the COVID-19 pandemic (Shaibu et al., 2021). Moreover, this research shows that many obstacles to justice prevent people from accessing it, getting a satisfactory result or getting any result. The lack of tangible or symbolic resources was evident in the complainants’ limited time, investigation and voice (Charman and Williams, 2022). Consequently, the following hypothesis has been proposed for the present study:


DJ moderates the positive relation between RL through AC and OCB such that the relationship is strengthened when DJ is high.


DJ moderates the positive relation between RL through AC and PS such that the relationship is strengthened when DJ is high.

Figure 1 shows the study’s model.

This study examines how RL affects various outcomes (OCB and PS). It also examines how AC mediates the links between PS, organizational citizenship and RL. RL, OCB and PS interact with DJ as a moderator through AC.

3. Methodology

3.1 Sample

The primary source of data collection was using a valid, structured questionnaire and a convenience sampling technique. The targeted group consists of the healthcare sector, whose employees work in multi- and super-specialty hospitals in India and deal with more than 50 patients per day. These data were gathered using multiple sources. Employees at the hospital are divided into two groups: middle-level employees (doctors, lab technicians, nurses and and managers) and lower-level employees (ward boys/girls, receptionists, sweepers, guards and operation theater [OT] staff). A third group is covered to obtain patient data. The questionnaire was distributed in 300 copies, both online and offline, but only 280 were returned; some questions were left blank or had incorrect information, so the final data sample included 275 respondents’ employees and patients. Demographic information can be mention in appendix Table A1 for employees and Table A2 for patients.

3.2 Measures

3.2.1 Responsible leadership

RL was measured using the scale from Voegtlin (2011). The six items on this scale were designed to operationalize RL in the context of employees’ impressions of supervisory activities. The questionnaire was simplified with some alternative or equivalent terms to make it easier for responders to grasp such as how often does your supervisor deal with doctors? What is the frequency with which your supervisor interacts with the patients? How often does your supervisor communicate with the housekeeping team?. Participants were given a five-point Likert scale to respond on, with 1 as most important and 5 as least important (1 being “Not at all” and 5 being “Frequently”).

3.2.2 Distributive justice

The organizational justice scale (Niehoff & Moorman, 1993) was used to measure DJ. This measure has one component for assessing DJ views and two for assessing procedural justice perceptions. The DJ dimension was used in this study. “My work schedule is fair” and “I believe my compensation is reasonable” are two examples of items on this scale. Five DJ items on this scale assess the fairness of various employment outcomes (Niehoff & Moorman, 1993). The participants were given a five-point Likert scale to respond on, with 1 as “Strongly disagree” and 5 as “Strongly agree.”

3.2.3 Affective commitment

The AC measured by Allen and Meyer (1990) organizational commitment scale. This scale contains one dimension for assessing AC and two for assessing continuation and normative commitment perceptions. The AC was used in this research. “I would be very happy to spend the rest of my career with this hospital,” and “I like discussing my hospital with individuals outside of it,” are two examples of items from this scale. The emotional attachment of the organization is measured on this scale through eight-item scale. Participants responded on a five-point Likert scale, with 1 as “Strongly disagree” and 5 as “Strongly agree.” For this research, the researchers made several changes to the translation.

3.2.4 Organizational citizenship behavior

OCB was measured with the 16-item scale developed by Lee and Allen (2002). Sample items from this scale are “Helps others who have been absent,” “Attend functions that are not required but that help organizational image” and “Adjust your work schedule to accommodate other employees’ requests for time off”. The participants were given a five-point Likert scale to respond on, with 1 as “Strongly disagree” and 5 as “Strongly agree.”

The items of the questionnaire mention in appendix Table A3.

3.2.5 Patient satisfaction

PS was measured with the six- item scale developed by Davis and Ware (1988). Sample items from this scale are “overall rating of the hospital,” “how do you rate your communication with the hospital staff,” and “Are you satisfied with the cost of healthcare financing.” The participants were given a five-point Likert scale to respond on, with 1 as “Strongly disagree” and 5 as “Strongly agree.”

4. Results and discussion

Correlation coefficient is the inferential statistical tool that determines the degree of closeness between two variables. The following table provides the correlation matrix among the variables generated by the SPSS 25. Each variable is perfectly correlated with itself (obviously) and that is why r = one along with the diagonal of Table 1 (Twigg, 2010).

RL is positively related to DJ, AC, OCB and PS with a Pearson correlation coefficient of r = 0.269**, r = 0.066*, r = 0.080 and r = 0.066 at a significant level of 0.01, meaning thereby there is a significant and moderate association among the variables.

The model fit indices show that the model has both goodness and badness fit. Table 2 displays the results of model fit indices in our model. CMIN/DF and RMSEA values are within the threshold limit (Browne & Cudeck, 1992), but goodness fit values (GFI, TLI and CFI) are not. It is less than 0.90. As a result, the model has a moderate fit. These indices should be greater than 0.80 though 0.70 is also acceptable (Benson & Fleishman, 1994; Curran, West, & Finch, 1996).

The validity is the evidence which showed correct inferences about the question, and it has aimed to answer and measured all the dimension considered in the study Field (2009). The degree to which a measurement precisely portrays what it claims to measure. Once validity is assured, the next step on the hand of a researcher is to ensure reliability, the degree to which the observed variables accurately measured the true value and error-free. More reliable measures will show greater consistency.

Confirmatory factor analysis (CFA) is a multivariate statistical approach that is employed to assess how well the measured variable shows the number of constructs. It is a tool for confirming or disproving measurement theory. The CFA is basically applied to test the two most widely used validity tests: convergent validity and discriminant validity. To investigate convergent validity more accurately which has four dimensions of each variable as indicators of their respective latent constructs and correlation among the latent variables was calculated.

Hence in this study, first, we checked the convergent validity, the degree to which two estimates the same notion is correlated. High correlations here imply the scale is measuring its intended notion (Hair, Anderson, Black, & Babin, 2016). The result of the present study confirmed that the values of the composite reliability (CR) and average convergent variance (AVE) ought to be more than 0.7 and 0.5. Therefore, there is no issue of convergent validity. Second, discriminant validity is the degree to which two notions that are similar are distinctive from one another. In the present study, the computed value of AVE and MSV suggest that there is no problem with discriminant validity. (See Table 3 for additional information). The value of AVE is more than maximum shared variance (MSV), suggesting no issues of discriminant validity.

4.1 Hypothesis testing

To test the hypotheses of the study, structural equation modeling multivariate techniques have been applied. It is most helpful in examining theories in which multiple equations involve dependence relationships (Hair et al., 2016). We tested the hypothesis H1 independent variable to dependent variable RL to OCB was found insignificant (β = 0.022, t = 0.765, P = 0.445, p < 0.001). Moreover, H2 was tested independent variable to dependent variable were also found insignificant related to RL to PS (β = 0.065, t = 1.22, P = 0.222, p < 0.001).

We use AMOS-22 testing the direct and indirect effect in mediation analysis to test the hypothesis H3, AC mediates the relationship among RL to OCB was found insignificant see the result Table 4. Further, H4, AC mediates the relationship between RL to PS were also, found insignificant see the result in Table 4.

The results discussing the moderation-mediation effect in the respect of H5, and H6. The overall results indicate the moderated mediation model was negatively supported in outcome variable OCB with the index = 0.068 (95% CI = −0.115; −0.015) and in case of outcome variable PS the overall moderated mediation model was not supported with the index = 0.12 (95% CI = −0.002; 0.030).

4.2 Test of moderated-mediation model

To examine the significance of the indirect effects at different levels of the moderator, the hypothesized moderation-mediation model was tested in a single model using a bootstrapping approach (Hayes, 2013). The predictor variable was RL, with AC serving as the mediator. The proposed moderator was OCB, PS and DJ. The conditional indirect effect of a moderating variable DJ on the relationship between a predictor RL and an outcome variable (OCB; PS) is tested using moderated mediation analyses. To test the significance of the indirect (i.e. mediated) effects moderated by DJ, i.e. conditional indirect effects, the “PROCESS MACRO” model 7, v2.16 (Hayes, 2013) in SPSS version 25 with bias-corrected 95 percent confidence intervals was used. The absence of zero within the confidence intervals supports significant effects.

4.3 Test of conditional indirect effect

The PROCESS macro model number 7 was used to test the hypothesized moderated-mediation model, which tests a model in which DJ moderates the effect of path (Hayes, 2013). The effect of RL and OCB, PS was found to be moderated by DJ. (Unstandardized interaction B = −0.104, Bse = 0.48, t = 2.45, p = 0.33). AC was not associated with OCB and PS, B = 0.22, Bse = 0.29, t = 0.761, p = 0.447, B = 0.65, Bse = 0.054, t = 1.214, p = 0.226. The overall moderated-mediation model was negatively supported by the outcome variable OCB with the index = 0.068 (95% CI = −0.115; −0.015) and in case of outcome variable, PS, the overall moderated mediation-model was not supported with the index = 0.12 (95% CI = −0.002; 0.030). Because zero lies within the CI, this indicates that DJ has an insignificant moderating effect on RL via AC Hayes (2015). The conditional indirect effect was not strongest in those high in DJ (1 SD above the mean of NFC; effect = −0.058, SE = 0.42, 95% CI = −0.141; 0.025) and weakest in those low in DJ (1 SD below the mean, effect = 0.079, SE = 0.046, 95% CI = −0.018; 0.166).

This graph shows (Figure 2) that no moderation effect (DJ) exits in the relationship between RL and AC in the case study of healthcare sector in India.

5. Limitations and future directions

While the study has several limitations, it does give the potential for future researchers. However, due to its practical nature and context-specificity, this study’s scope is limited to India’s healthcare sector; this constraint is difficult to overcome. The small sample size of this study is another loophole. Due to a lack of access to the whole staff list, obtaining a random sample is impossible. From research to production to facility management, the healthcare industry comprises a vast range of operations. Employees and patients in multispecialty hospitals, both public and private, are the subject of this study, which does not cover the viewpoints of employees and patients across India’s whole healthcare system. Employees and patients in multispecialty hospitals, both public and private, are the subject of this study, which does not cover the viewpoints of employees and patients across India’s whole healthcare system. Furthermore, the survey’s majority of respondents were males, and the results reflected the perspectives of male employees, which is one of the study’s possible outcomes. In addition, there are few studies on RL in India. In the context of a developing country, such a concept is critical, and this study shows that it has a considerable impact on organizational outcomes.

Furthermore, future research may uncover another moderator and mediator, allowing the hypothesized model to be improved and the study’s findings to be more clearly understood. Researchers can see how much effect RL can have on influence extra-role behavior and PS by including emotional exhaustion, normative commitment, continuance commitment, organizational injustice and green human resource management (HRM) as mediators and moderators. Similar research in many cultural situations will also add to the existing knowledge domain.

6. Theoretical and practical implication of the study

This study makes numerous contributions from both a theoretical and practical perspective. The current study also introduces a conceptual model and theoretical framework that significant contribution to employee OCB and RL. The two variable outcomes PS (in terms of customers) and extra-role behavior (in terms of employees) are being explored for the first time in an Indian context, which is the study’s unique contribution. Organizations have realized that creating a DJ working environment is vital for long-term success, while unethical behavior has a negative impact on organizational performance. DJ is a significant research issue in the health sector because it has an impact on patient–organization interactions. The current work provides a strong theoretical foundation by incorporating the TPB and stakeholder theory to confirm the role of OCB and PS in the performance of healthcare sector. We are all aware that the healthcare sector is a service-based industry that is completely dependent on competent human resources. The findings confirm the necessity of DJ as a moderator of the employee’s perspective and AC in the role of mediating variable to enhance the overall performance of employees as well as to motivate the extra-role behavior in the organization. By recognizing the relevance of RL in the healthcare sector, our study adds to the literature on RL.

The current study also shows some useful implications for the top management in healthcare organizations, particularly in the Indian context. In the Indian healthcare sector, there is a need to deal with 21st-century problems like how care should be safe, effective, patient-centered, quick, efficient and fair in terms of how resources are shared. This can be done with the help of responsible leaders. This study confirms a significant association among RL, DJ, AC and citizenship behavior. RL creates an ethical foundation to influence employee performance as well as extra-role behavior and retaining the staff in the long-term organizational success. Given the importance of employee attitudes in providing high-quality service and establishing long-term relationships with patients in the healthcare industry, RL is a valuable strategy for improving business performance over other healthcare sectors. The practical implications of these findings, supervisors and HR managers, as well as the healthcare industry, will benefit greatly from this research. We believe that the healthcare industry should adopt an intensive leadership training program for HR managers to assist them in recognizing the value of RL and developing related behaviors such as sustaining ethical behavior and inspiring employees to foster positive attitudes. The findings show that DJ and AC are important factors in deciding to citizenship behavior.

7. Conclusion

The goal of this research is to investigate how RL behavior promotes OCB and PS, using the assumptions of stakeholder theory and the TPB as a guide. The effect of RL on OCB and PS was seen insignificant in the Indian healthcare sector. Moreover, this study also investigates AC mediators in the healthcare sector which do not influence extra-role behavior and PS. Furthermore, the findings show that the moderation-mediation effect of DJ through AC strengthened the connection between RL and OCB, but in case of PS, no moderation-mediation effect was found in our study. As a result, commitment is unlikely to influence extra-role behavior and PS.


Hypothesized model

Figure 1

Hypothesized model

The effect of moderation-mediation model

Figure. 2

The effect of moderation-mediation model

Correlation statistics

MeanStd. deviationR_LD_JA_CO_C_BP_S

Note(s): **p < 0.01

Model-fit indices

CFA model1.9510.8140.8410.8530.059
Cut-off value1.0−3.0>0.90>0.90>0.90<0.80

Note(s): GFI = goodness-of-fit index; TLI = Tucker–Lewis’s index; CFI = comparative fit index; RMSEA = root mean square of approximation

Validity and reliability statistics

ConstructsStatementsAVECRFactor loading
RL2 0.750
RL3 0.715
RL4 0.711
RL5 0.723
RL6 0.801
DJ2 0.733
DJ3 0.669
DJ4 0.835
DJ5 0.793
AC2 0.749
AC3 0.673
AC4 0.740
AC5 0.653
AC6 0.662
AC7 0.547
AC8 0.549
OCB2 0.758
OCB3 0.660
OCB4 0.638
OCB5 0.691
OCB6 0.589
OCB7 0.637
OCB8 0.686
OCB9 0.614
OCB10 0.645
OCB11 0.712
OCB12 0.641
OCB13 0.653
OCB14 0.679
OCB15 0.613
OCB16 0.655
PS2 0.679
PS3 0.628
PS4 0.621
PS5 0.715
PS6 0.524

Mediation result (total effect, direct effect and indirect effect)

RL, AC, and OCB

OCBStd. estimationp-valueResult
Total effect0.0800.240Insignificant
Direct effect0.0310.458Insignificant
Indirect effect0.0480.326Insignificant

RL, AC, and PS

PSStd. estimationp-valueResult
Total effect0.0660.261Insignificant
Direct effect0.0730.213Insignificant
Indirect effect−0.0070.203Insignificant

Employee (N = 275)

Marital statusMarried
AgeUp to 30 years
Above 50
EducationHigh School
Higher education
Family incomeUp to 20,000
Above 80,000
Job profileDoctor
Lab tech
Ward boy
Medical plumber
Medical sweeper
Forensic lab
Pathology worker
OT staff
Ward women
Pathology worker
OT in charge
Organization statusPrivate
Nature of jobPermanent

Source(s): Authors’ own elaboration

Patient (N = 275)

Above 50
Marital statusMarried
EducationPrimary education
High school
Higher education
Hospital visitFirst visit
Repeat visit
Organizational statusPrivate

Source(s): Prepared by the researcher

Items of the questionnaire

Responsible leadership
  1. How often your supervisor interacts with the doctors (sitting/visiting)

  2. How often your supervisor interacts with healthcare staff (clerical staff, lab assistants, etc.)

  3. How often your supervisor interacts with the patients?

  4. How often your supervisor interacts with the caregivers (relatives, family, friends, etc.) with patients?

  5. How often your supervisor interacts with the housekeeping staff?

  6. How often your supervisor interacts with the medical representatives or mediclaim agents?

Distributive justice
  1. I feel that my workload is quite fair, according to the job profile

  2. I thought that I am getting an appropriate salary, according to workload

  3. I feel that my job responsibility is fair

  4. I feel that my compensation and perquisites are equally distributed

  5. In the end, the rewards which I have received are quite fair

Affective commitment
  1. I would be very happy to spend the rest of my career with this hospital

  2. I enjoy discussing my hospital with people outside it

  3. I really feel as if this hospital problems are my own

  4. I think that I could easily become as attached to another hospital as I am to this one

  5. I do not feel like “part of the family” at my hospital

  6. I do not feel “emotionally attached” to this hospital

  7. This hospital has a great deal of personal meaning for me

  8. I do not feel a strong sense of belonging to my hospital

Organizational citizenship behavior
  1. (1)

    Helps others who have been absent

  2. (2)

    Attend functions that are not required but that help organizational image

  3. (3)

    Willingly give your time to help others who have work-related problems

  4. (4)

    Keep up with developments in the organizations

  5. (5)

    Adjust your work schedule to accommodate other employees’ requests for time off

  6. (6)

    Defend the organization when other employees criticize it

  7. (7)

    Go out of my way to make newer employees feel welcome in the work group

  8. (8)

    Show pride when representing the organizations in public

  9. (9)

    Show genuine concern and courtesy towards coworkers, even under the most tying business of personal situations

  10. (10)

    Offers ideas to improve the functioning of the organizations

  11. (11)

    Give up time to help others who have work or nonwork problems

  12. (12)

    Express loyalty toward the organization

  13. (13)

    Assist others with their duties

  14. (14)

    Take action to protect the organization from potential problems

  15. (15)

    Share personal property with others to help their work

  16. (16)

    Demonstrate concern about the image of the organization

Patient satisfaction
  1. Overall rating of the hospital

  2. How do you rate your communication with the hospital staff?

  3. How do you rate your communication about medicine with pharmacist?

  4. Are you satisfied with the cost of healthcare financing?

  5. How do you feel about the time it takes to visit a doctor after you have registered?

  6. How do you rate your communication with doctors?

Appendix Demographic information of employee and patient satisfaction

Appendix 2


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Corresponding author

Zeba Khanam is the corresponding author and can be contacted at: zkhanam7@gmail.com

About the authors

Zeba Khanam is a research scholar at Aligarh Muslim University. Her focus is on human resources development and RL. She is researching RL and organizational commitment. In 2016, she finished her master’s at CSJM. University Kanpur.

Dr Sheema Tarab (Assistant Professor) is an Aligarh Muslim University assistant professor. She has a Ph.D. in commerce, and her focus is on HRD. She has published two book chapters, eight peer-reviewed articles, presented papers at national and international conferences, and spoken at multiple academic programs. She earned a Ph.D. at Aligarh Muslim University in 2012.

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