Matching Ethical Climate to Nurses’ Service Behaviors in Public and Private Hospitals: A Cross-Sectional Study

Background: Workplace climate is great signicant element that has impact on nurses’ behavior and practice; moreover, nurses’ service behavior contributes to the patients’ satisfaction and subsequently to the long-term success of hospitals. Few studies explore how different types of organizational ethical climate encourage nurses to engage in both in-role and extra-role service behaviors, especially in comparing the inuencing process between public and private hospitals. This study aimed to compare the relationship between the ve types of ethical climate and nurses’ in-role and extra-role service behaviors in public and private hospitals. Methods: This study conducted a cross-sectional survey on 559 nurses from China. All participants were investigated using the Ethical Climate Scale and Service Behavior Questionnaire. SPSS 22.0 was used for correlation analysis, t-test and analysis of variance test, and Mplus 7.4 was used for group comparison. Results: The law and code climate has a much greater inuence on nurses’ in-role service behavior in private hospitals than on that in public hospitals (β = -.277; CI 95% = [-.452, -.075]; p < .01), and the instrumental climate has a stronger inuence on nurses’ extra-role service behavior private hospitals than on that in public hospitals (β = -.352; CI 95% = [-.651, -.056]; p < .05). Meanwhile, the rules climate has a greater effect on nurses’ extra-role service behavior in public hospitals than it does in private hospitals (β = .397; CI 95% = [.120, .651]; p < .01). Conclusions: As the relationship between the ve types of ethical climate and nurses’ in-role and extra-role service behaviors in public and private hospitals were different, the strategies used to foster and enhance the types of ethical climate are various from public to private hospitals. The caring and instrumental climate are the key to promote extra-role service behavior for nurses in private hospitals. And independent climate has great effect on extra-role service behaviors for nurses in public hospitals. our research indicates that (1) in private hospitals, the law and code climate had a much greater inuence on nurses’ in-role service behavior than it did in public hospitals, and (2) the instrumental climate had a greater effect on private hospital nurses’ extra-role service behavior than on those in public hospitals; however, (3) the rules climate had a greater effect on public hospital nurses’ extra-role service behavior than on those in private hospitals.

plays an important role by the informal atmosphere, such as in languages, role models, behavioral norms, rituals, and historical anecdotes [19,23], which suggests that the ethical climate will lead to a higher level of extra-role service behavior. In the year of 1975, Schneider strongly believed that because of the diversity of climate types that exist within an organization, it is imperative that researchers focus on those dimensions of climate that are associated with speci c variables, rather than focusing on the climate in general [24]. However, evidence speci c to the effect of different ethical climate types on nurses' inrole service behaviors and extra-role service behaviors remains limited.

Hospital ownership and service behavior
In recent ten years, private hospitals in China have developed rapidly, but they are in fact designated as the supplement of public hospitals [25]. Because public hospitals account for the majority of hospitals in China, and they play the vital roles in keeping citizen's health and responding to emergency public health crisis, such as the COVID-19 pandemic. Of course, the public hospitals in China have signi cant medical resource advantages, public hospitals are in a better position to recruit health care workers and provide services [25]. In China, most private hospitals are primarily pro t-driven, and for this reason, it makes sense that private hospital services are largely determined by the market. Private hospitals adopt the marketing concept and seek to attract patients by concerning patients' satisfaction and providing consumer-oriented services [26]. In addition, there are different employment contracts for nurses in public and private hospitals, such as permanent contract, xed term contract, and agency employment contract [26]. Various contract types not only present different salary and compensation systems, but also different job requirements for nurses to stay in their organizations. Therefore, nurses in different ownership hospitals may act differently in nursing service behaviors.
Additionally, the difference of hospital ownership implies potentially different resources, operation modes and climates. The issue as to whether hospital ownership has an impact on the quality of nursing service has long been a serious concern [27]. Some researchers argue that nurses in public hospitals perform better than those in private hospitals [28,29]. However, others argue the reverse conclusions [30]. Since the nurses' service behavior contains the moral philosophy with core values that considering patient's wants, needs, and preferences [6], ethical climate may be the direct and effective explanations of service behavior, and can clarify the mixed associations between hospital ownership and nursing service behavior. The hospital ownership may moderate the relationships between ethical climate and nurses' service behavior, especially in China. Considering hospital ownership has both the theoretical and practical contributions in the study of ethical climate and service behavior, that help researchers nd a key factor for service behavior research and inspire nursing managers to propose down-to-earth managerial solutions.

Aim
This research aims to compare the links between various ethical climate types and nurses' in-role and extra-role service behaviors in public and private hospitals.

Design and sample
A pilot test was conducted for the initial questionnaire after being developed by three doctors in management and nursing. Based on the type of related questions, the length of the questions, the answer options, and the time to complete the questionnaire in the feedback, the questionnaire was modi ed and improved, resulting in the nal questionnaire.
WeChat is the most frequently used social networking tool by Chinese individuals [31]. Therefore, it is convenient and widely used to conduct surveys via WeChat. In May 2019, the questionnaire was sent to nurses through the third author's WeChat account. Using the snowball sampling method, each respondent was asked to share the questionnaire with their nurse colleagues via WeChat. Totally 620 respondents sent back their questionnaires at last. After deleting 61 invalid questionnaires with duplicate IP addresses in responses and short completion times (under 200 seconds), there were 559 valid questionnaires in total in China.

Measures
All measurements were made in Chinese. Since the relevant concept of ethical climate was originally produced in English, a back-translation procedure form English to Chinese was used [32], and there were no signi cant linguistic differences between these two sets of concepts. Additionally, all methods were performed in accordance with the relevant guidelines and regulations.
Ethical Climate. Following Abou's [33] research, ethical climate was measured use the questionnaire introduced and authorized by Cullen et al. [34], which was completed to measure nurses' views on the ethical atmosphere of their a liations. The scale comprised 24 items and is divided into ve dimensions: law and code (4 items), rules (4 items), instrumental (6 items), and independent (5 items). We measured the outcomes using a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). The higher the ethical climate score, the higher the nurse's perception of the ethical climate. The internal consistency, measured using Cronbach's α, was 0.865, 0.886, 0.853, 0.881 and 0.853 for caring, professional, rules, instrumental and independent, respectively.

Service
Behavior. An eight-item scale developed by Chen [35] was adopted to measure nurses' service behaviors, and two dimensions were included in the scale, consisting of in-role service behaviors and extra-role service behaviors. In this study, the authorized nurses' service behavior scale was used [36]. All the survey items were rated on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). The higher score means the level of nurses' service behavior can be higher. Cronbach's α for in-role service behavior and extra-role service behavior was 0.923 and 0.835, respectively.
(M), standard deviation (SD), number (n) and percentage (%) as appropriate. Group differences of continuous variables were tested by t-test or one-way ANOVA. We then presented the means, standard deviations, and correlation values among the study variables. As hospital ownership is a binary variable, whether public or private hospitals, in the end we used group comparison to compare the link between the ethical climate types and the service behaviors of nurses in public and private hospitals, respectively with Mplus 7.4.

Descriptive statistics
Of all the nurses who participated in the survey, 94.7% were female, were of young age (88.7% under 40 years of age) and had college education (51.1% with a bachelor's degree or higher). The respondents' demographic information and group differences on in-role and extra-role service behaviors are described in detail in Table 1. Participants with high level of in-role service behaviors were > 40 years old (p < .001), worked for 11-15 years (p < .001), had bachelor's degree (p < .001), had senior nurse professional title (p < .001), temporary employed (p < .001) and were from public hospitals (p < .001). Nurses who had higher level of extra-role service behaviors were > 40 years old (p < .001), worked for 16-20 years (p < .001), had master's degree or above (p < .001), had junior nurse professional title (p < .001), and temporary employed (p < .001).   Subsequently, we tested the moderating effects of hospital ownership on ethical climate types and nurses' service behaviors [37]. As shown in Table 4

Discussion
Interpreting the ndings This study is the rst to compare the connection between ethical climate types and in-role and extra-role service behaviors of nurses in public and private hospitals. It con rmed that perceptions of ethical climate type in uenced the extent to which nurses engaged in in-role and extra-role service behaviors. These comparisons indicated that nurses' service behavior is a complex notion that is in uenced by many organizational factors, thus contributing to the nursing service management literature.
Firstly, the outcome of the current study con rms that the caring climate and rules climate in public hospitals signi cantly predicted both nurses' in-role service behavior and extra-role service behavior. Because the caring climate is linked with the construct of benevolence and the individual and local locus of analysis, nurses working in caring climate believe that their service behaviors should be based on an overall concern for the well-being of others not only in-role behaviors but also extra-role behaviors. The results in this study are consistent with previous studies suggesting that a caring climate was signi cantly correlated with nurses' ethical behaviors [24,38]. Additionally, this conclusion is showing consistence with the literature, which indicates that a caring climate is related to positive extra-role service behavior [39]. As the rules climate is associated with the principle construct and the local locus of analysis, in this climate, it is generally accepted that nurses' service decisions are guided by a strong and universal set of local rules or standards, such as codes of conduct [40][41][42]. Moreover, the rules climate was found to have a greater effect on nurses' service behaviors than a caring climate. This result is in line with Abou's [33] study, which showed that nurses believed that the most frequent or common ethical climate is rules guided. A possible explanation might be that most nurses perceived that the rules climate was signi cant and that "rules and procedures are to be strictly followed" [43].
Second, the law and code climate only signi cantly in uenced nurses' in-role service behavior in both public and private hospital. A law and code climate involves an organization that supports principled decision-making based on external criteria, which includes laws or professional codes of conduct. Hence, we found that nurses in a law and code climate tend to devote themselves to their professional duties and provide more in-role service behavior.
Moreover, it was found that nurses in public hospitals rather than private hospitals in the independent climate acted more extra-role service behaviors.
Because in an independent climate, nurses acted according to the personal moral beliefs of their own based on their set of well thought out principles and served patients in a way that exceeded their formal job requirements. Therefore, based on the above ndings, we suggest that managers in public hospitals should focus on the development of the caring, rules, law and code, and independent climates. It is particularly important to address the caring and rules climates.
Third, it was found that private hospital nurses provided more in-role service behavior if they perceived a greater law and code and rules climate, which is consistent with the results in public hospitals outlined above. We can conclude from these results that the existence of an ethical climate type of law and code in both public and private hospitals is in line with the idea of promoting the public interest, as this type emphasizes the principles of fairness, accountability, transparency, and equality [44,45]. All nurses should be provided with hospital education and training courses so that they are aware of and have knowledge of the guidelines and rules formulated by professional institutions or laws promulgated by the government. Nurses will thus provide more in-role service behavior and satisfy patients.
caring climate, the main consideration is how to maximize the interests of everyone in the organization, and nurses in both public and private hospitals who feel a caring climate will integrate themselves into their work and in turn provide additional services to their patients [46]. One important nding from the research suggests that although in an instrumental environment, the goal of the rst importance is to provide the interests of the organization or to serve personal bene t with little regard for the needs and interests of others [33], private hospital nurses perceiving a more instrumental climate are willing to exhibit greater extra-role service behavior, which is in contrast with Leung's [39] nding that an instrumental climate is associated with negative extra-role behaviors. A possible explanation may be that private hospital nurses provide additional services to patients spontaneously, which implies more extra-role service behaviors that bene t patients and thus contribute to nurses' performance. This observation is consistent with Simha and Cullen's [47] idea that the instrumental climate encourages employees to seek out better prospects for themselves and has a signi cant positive in uence on nurses' continuance commitment [48].
Lastly, when comparing the in uences of ethical climate types on nurses' service behavior in different ownership hospitals, our research indicates that in private hospitals, the law and code climate had a much greater effect on nurses' in-role service behavior than it did in public hospitals. It is recommended that hospital authorities in China establish comprehensive legal and professional rules and internalize them more effectively in private hospitals so that the law and code climate can have a greater impact on the in-role service behavior of nurses in private hospitals. In addition, ndings from the study indicate that the instrumental climate had a greater effect on private hospital nurses' extra-role service behavior than it did in public hospitals. According to Victor and Cullen [16], the instrumental climate is closely linked to egoistic structures and personal and local points of analysis. As a result, nurses working in the instrumental climate tend to perceive their organization as encouraging norms of ethical decision-making and expectations from an egoistic perspective. Especially for private hospital nurses, an instrumental climate would encourage them to provide much greater extra-role service behavior to facilitate their job performance and seek better prospects for themselves. However, the conclusions of this study demonstrated that the rules climate had a greater effect on public hospital nurses' extra-role service behavior than on those in private hospitals. Because of the close link between the rules climate and the accepted rules of conduct de ned by the organization, we can conclude that the rules climate ensures that public hospital nurses strictly adhere to hospital rules and procedures and perform extra-role service behaviors.

Implications for nursing management
Understanding the relations between the types of ethical climate and the dimensions of service behavior is conducive to the generation of incentive strategies for nurses. As the hospital ownership has an impact on the quality of nursing service, the ndings provide a clear and valuable information about how public and private hospitals administrators motivate nurses to deliver high-quality care and service. The caring and instrumental climate are the key to promote extrarole service behavior for nurses in private hospitals. And independent climate has great effect on extra-role service behaviors for nurses in public hospitals.

Limitations
There are some limitations of this study that may affect the results. One potential limitation is that since all variables are measured by self-report, which may suffer from response bias in each respondent [49]. Second, this study experienced a variable-centered method that presumes that employees provide all aspects of service behaviors equally. This research approach is similar to previous studies testing service behavior. In fact, various dimensions play a variety of roles. A person-centred approach can use latent trait surveys to gain insight into service behaviors, in other words, to understand the typology of service behaviors. Lastly, this study focused primarily on the moderating effect of hospital ownership on the connection between the service behavior dimensions and the type of ethical climate. Future research should examine the psychological process that how ethical climate affect nurses' service behaviors and also explore the interaction effect of individual and organizational factors on service behaviors of nurses.

Conclusions
The outcomes of this study indicate that a caring and rules climate in public hospitals signi cantly predicted both nurses' in-role service behavior and extrarole service behavior. In addition, an independent climate only in uenced their extra-role service behavior. In regard to private hospitals, if nurses perceived a greater law and code and rules climate, they provided more in-role service behavior, and if they perceived a greater caring and instrumental climate, they provided more extra-role service behavior. In comparing the two ownership hospitals, our research indicates that (1) in private hospitals, the law and code climate had a much greater in uence on nurses' in-role service behavior than it did in public hospitals, and (2) the instrumental climate had a greater effect on private hospital nurses' extra-role service behavior than on those in public hospitals; however, (3) the rules climate had a greater effect on public hospital nurses' extra-role service behavior than on those in private hospitals.
Abbreviations ISB: In-role service behavior; ESB: Extra-role service behavior

Declarations
Ethics approval and consent to participate The research design was approved by the biomedical research ethics committee of Medical College of Hebei Engineering University. Data privacy and con dentiality were maintained and assured by obtaining subjects' informed consent to participate in the research. All methods were performed in accordance with the relevant guidelines and regulations.