Research on the Correlation Mechanism of Psychological Contract Violation and Physicians’ Behaviour Options (EVLN) in Tertiary Public Hospitals: An Empirical Study in Beijing, China

Background: With the continuous deepening of the new medical reform, the hospital management system has changed, and there have been corresponding changes at the organisational and individual levels. As the main body of medical services, how to effectively motivate physicians is an important issue for hospital management. Purpose: the purpose of this research was to investigate the correlation mechanism between psychological contract violation and the EVLN behavior of physicians in tertiary public hospitals and explore new ideas for encouraging physicians, and provides governance and intervention strategies for management in hospitals. Methodology: Based on related theories such as psychological contract, this research used the stratified cluster sampling method to survey a total of 321 physicians in four public hospitals in Beijing, established an Excel database, and used Stata15.0 to construct regression models to analyse the correlation mechanism between psychological contract violation and the EVLN behavior of physicians in tertiary public hospitals. Findings: Psychological contract violation has a positive effect on exit behavior and neglect behavior, and a negative effect on voice behavior and loyalty behavior. Organisational justice has a mediating effect on the direct correlation mechanism models. Practice Implications: Our results suggest that it is necessary to pay attention to the psychological contract violation of physicians, build a good psychological contract relationship between public hospitals and physicians, and make full use of the role of organisational justice to promote positive behaviors of physicians, and moreover to prevent and curb negative behaviors of physicians.


Introduction
In China, public hospitals that absolutely dominate the market are positioned as public welfare institutions. In 2009, China started a new round of medical and health system reforms, including the establishment of a corporate governance structure, the adjustment of medical service prices, the improvement of basic medical security payment, a hierarchical diagnosis and treatment system, and the establishment of a modern hospital management system policy. These reforms changed the external environment, internal organisational structure, and operational management of the public hospital. In the face of rising medical service costs, continuous fee control measures by medical insurance departments and patient concerns regarding service quality, hospitals are facing unprecedented pressure. Physicians hold a centrally important function in hospitals, with a monopoly on decision-making with regard to admitting and discharging patients, selecting and performing clinical procedures, and prescribing pharmaceuticals. Thus, physicians are critical to a hospital's organisational success.
For a long time, Chinese medical staff have faced harsh professional environments, with long working hours, high pressure, insufficient labour value, and strained physician-patient relations, especially with the frequent occurrence of severe injuries.
According to incomplete statistics, from July 2001 to July 2018, there were a total of 47 injury and medical cases resulting in the death of medical staff, which greatly affected the sense of security and practice confidence of medical staff. The 'Physician Occupation Satisfaction' survey conducted by the China Youth Daily Social Survey Centre and APP 'Physician Chunyu' on 467 medical workers showed that 39.6% of the interviewed physicians clearly expressed dissatisfaction with their work (2015) [1]. A 2015 survey that reported on the attrition of physicians disclosed that in the first, second, and third level hospitals, the percentages of physicians who had resigned were 45.4%, 58%, and 63.4%, respectively. The turnover of physicians not only causes an increase in human resources costs, but also affects the quality of medical care and further aggravates the relationship between physicians and patients. Many hospitals are confronted with a physician shortage. Some, especially young physicians, choose to give up their medical work and move to other industries, which is a huge loss for both individuals and society.
In response to these challenges, hospitals have attempted to improve the hospital-physician relationship. Previous literature used psychological contract theory to study the hospital-physician relationship and found that the fulfilment of the psychological contract can result in positive attitudinal and behavioural responses of physicians, such as job satisfaction and organisational citizenship behaviour (Bellou, 2009;Trybou, 2017) [2,3]. The violation of the psychological contract can result in negative attitudinal and behavioural responses of physicians, such as job dissatisfaction and thoughts of quitting (Bunderson,2001;Trybou, 2015) [4,5]. Different from the international mainstream model that physicians are free practitioners, in China, physicians are 'unit persons' and affiliated with medical institutions. As mentioned above, China's public medical institutions are public welfare institutions, and physicians affiliated with them are given the identity of an institution establishment worker, which is similar to a civil servant. These systems hinder the normal flow of Chinese physicians. Differences in Chinese and Western cultures maybe make Chinese physicians' behavioural choices in the case of psychological contract violation different. Only a few articles have studied the scale of Chinese physicians' psychological contract or the relationship between the psychological contract and job satisfaction, turnover intention, and passive loyalty (Zhang, M., et al, 2017; Wu, ZY., 2013; Zhou, P., 2019) [6][7][8]. Leineweber, C. et al. (2020) [9] found that group turnover were negatively with changes in interpersonal justice perceptions. Zhou, P. (2019) [8] explored the mechanism between physicians' psychological contract violations and their turnover willingness with the mediating effects of perception of organisational justice. Obviously, research into the behavioural choices of Chinese physicians is insufficient, especially since behaviours like suggestion and neglect have not been studied yet. This study summarises physicians' behavioural choices facing psychological contract violations under the framework of EVLN (Exit, Voice, Loyalty and Neglect) behaviour. Based on the theory of psychological contract violation, this study included physicians in public hospitals in Beijing as the research object to study the mechanism between physicians' psychological contract violation and different behaviour choices, aiming to better understand the psychological and behavioural changes of physicians in public hospitals under the background of organisational change, and create a better hospital-physician relationship.

Psychological contract violation (PCV)
The psychological contract refers to 'individual beliefs, shaped by the organisation, regarding terms of an exchange agreement between individual and organisation (Rousseau, 1995) [10]. Schein (1980) [11] pointed out that the 'self-evident' contract that exists in people's minds, although it is not stated, is a powerful determinant that affects employees' attitudes and behaviours toward the organisation. A violation of the psychological contract occurs when an employee perceives that the organisation has failed to fulfil one or more of its obligations comprising the psychological contract (Rousseau & Parks, 1993) [12]. Previous researchers conclude that psychological contract violation may occur when the organisation violates on purpose or due to unforeseen reasons, and it may also occur when employees' understanding of organisational commitments is inconsistent with that of the organisation (Rousseau, 1995 [15][16][17][18][19][20]. There is no unanimous conclusion regarding the discussion of psychological contract dimensions.
Due to different employment conditions, the dimensions and specific content of the psychological contract will also be different. This research suggests that the psychological contract can express its meaning regardless of dimensions.

EVLN behaviour
Hirschman (1970) [21] summarised the employee's response to job dissatisfaction into the 'EVL' model: exit behaviour (Exit), advocacy behaviour (Voice), and loyal behaviour (Loyalty). Farrell (1983) [22] added neglect behaviour to the model to form the EVLN theoretical model, which was later extended by many other scholars. 'Exit' is the tendency and behaviour of employees to leave the organisation through resignation, transfer, or finding a new job within the organisation. 'Voice' refers to the behaviour of employees to improve their environment and conditions through active efforts such as discussing work difficulties with their supervisors or colleagues, proposing solutions, taking actions to solve the difficulties, and even seeking outside help. 'Loyalty' refers to the behaviour of employees to passively but optimistically wait for improvement of the environment and conditions by giving the organisation public and private support and acting as a well-behaved citizen. 'Neglect' refers to the behaviour of employees temporarily abandoning work by reducing effort, being late or absent for a long time, doing private tasks during working hours, and increasing the error rate. According to the active-passive dimensions, 'Exit' and 'Voice' are active responses, whereas 'Neglect' and 'Loyalty' are passive responses. According to the destructive-constructive dimensions, 'Exit' and 'Neglect' are destructive behaviours, while 'Voice' and 'Loyalty' are constructive behaviour (Farrell, 1983) [22]. Later scholars divided voice behaviour into aggressive voice and considerate voice (Hagedoorn & Buunk, 1998;VanDyne, 1998;Hagedoorn et al, 1999;Liljegren, 2008) [23][24][25][26]. In this study, the considerate voice is used for the study of physician voice behaviour based on the EVLN model of Farrell (1983) [22].

Organisational justice as a mediator
Organisational justice refers to the perceptions of fairness in organisational decision-making and resource allocation (Greenberg, 1987) [27]. Research on organisational justice began with Adams (1965) [28]. His research focused on the 'results' of distribution and put forward the concept of distributive justice (DJ). Thibaut & Walker (1975) [29] attached importance to the distribution procedure before the distribution result, and proposed the concept of procedural justice (PJ). Then, Bies & Moag (1986) [30] proposed the concept of interactive justice, which refers to the impact of the performer's attitudes and methods on employees' perception of fairness. Greenberg (1990) [31] divides interactive justice into interpersonal justice and informational justice. This study mainly focuses on the two most basic dimensions of procedural fairness and distribution fairness. Previous studies have found that organisational justice can strongly influence the relationship between psychological contract violation and employee response

Study framework
EVLN theory provides a framework for employees' responses to psychological contract violation. As shown in Figure 1, physicians will respond to psychological contract violation by increasing turnover and negligence, as well as reducing their voice and loyalty; psychological contract fulfilment will increase physicians' positive behaviours because their needs are met to a greater degree. The greater the contract violation or imbalance, the greater the possibility of employees' anti-production or withdrawal behaviour (Chatman, 1991;Griffeth et al, 2000) [33,34]. Thus, this paper proposes the following hypotheses: Hypothesis1 Psychological contract violation is significantly related to physicians' EVLN behaviours.
Hypothesis 1a Psychological contract violation is negatively related to physicians' constructive behaviours in public hospitals, including 'voice' and 'loyalty' behaviours.
Hypothesis 1b Psychological contract violation is positively related to physicians' destructive behaviours, including 'exit' and 'neglect' behaviours.
In Figure 1, organisational justice plays a mediating effect on the relationship between psychological contract violation and physician's behaviours. Once physicians perceive a violation of the psychological contract, they may feel unfairly treated and dissatisfied, thereby affecting their behaviour choices. The previous literature has demonstrated that physicians have higher job satisfaction, less turnover intention, more affective organisational commitment, and are more motivated to contribute to the mission statement when they perceive a high level of fulfilment of the psychological contract and organisational justice (Bunderson, 2001;Trybou, 2016Trybou, , 2017 [4,35,3]. Thus, this paper proposes the following hypotheses: Hypothesis 2 Organisational justice plays an intermediary role between physicians' psychological contract violation and EVLN behaviour.
Hypothesis 2a Psychological contract violation is negatively related to organisational justice.
Hypothesis 2b Organisational justice is significantly related to physicians' EVLN behaviour.

Sample and data
In China, large public hospitals mainly refer to tertiary-A public hospitals. This study collected data from physicians at four top public hospitals in Beijing, including two general public hospitals and two specialised public hospitals, using questionnaire-based

Instruments
To satisfy the content validity, the instruments in this study were modified from the relevant literature that have shown sound levels of reliability and construct validity.
Several steps were used to select items for the questionnaire. First, we translated the items from the existing English instruments into Chinese. Second, expert consultation including two professors and three hospital human resource managers provided assistance in scrutinising the appropriateness of the Chinese version of the questionnaire.
Third, a small sample presurvey was executed for modifying the instrument. A five-point Likert was used, ranging from 5 for 'highly agree' to 1 for 'highly disagree'; exploratory factor analysis was used to extract the initial solution. As a rule of thumb, items that and procedural justice and distributive justice each had six items.

Analysis
This study used Stata 15.0 for descriptive statistics analysis, exploratory factor analysis, and regression modelling. Cronbach's alphas and coefficients were used to assess the reliability and validity of the scales. The Sobel test (1982) [39] was used to explore the mediating effect of organisational justice between psychological contract violation and EVLN behaviour . The relationship between the variables was: (1) EVLN = β 11 PCV + β 10 ; (2) Justice = β 21 PCV + β 20 ; (3) EVLN = β 31 PCV + β 32 Justice + β 30 . A significant mediating effect must satisfy: 1. The independent variable in equations (1) and (2) (3), the influence of the independent variable on the dependent variable must be weakened or eliminated, β31 < β11 (partial mediation) or β31 is not significant (complete mediation).
Respondents with a Master's degree or above accounted for 84.30%. Physicians from general hospitals accounted for 71.92% and those from specialist hospitals accounted for 28.08%. Physicians of key disciplines comprised 51.00%, while physicians of non-key discipline comprised 49.00%. As for working years, 30.50% of respondents had worked ≤5 years, 25.70% had worked 6-10 years, 14.70% had worked 11-15 years, and 29.10% had worked 16 years and above. Respondents who were chief physicians accounted for 7.20%, deputy chief physicians were 27.70%, 33.90% were attending physicians, and physicians or below comprised 31.20%.

Reliability and validity analysis
For composite reliability, the recommended value should exceed 0.7 (Hair et al., 2010) [35]. The results reveal that the composite reliability of each construct reached 0.7.
The establishment of content validity is to ensure that the scale contains appropriate and representative items that can measure the concept (Haynes, Richard & Kubany, 1995) [40], generally using qualitative methods. In this study, the measures of constructs in this study were mainly based on domestic and foreign studies, and were modified for use. Thus, the measures used comply with standards of content validity and, hence, this study has content validity.
This study used exploratory factor analysis (EFA) to test convergent validity, which applied factor loading with a value exceeding 0.5 as the evaluation standard. If the factor loading for a measure fails to reach this value, this measure was not representative and was removed (Holden R J., 2010) [41]; otherwise, it was retained since its value exceeded the standard. This study applied the measurement model to verify the factor loading of various measures. The factor loading for construct measures must exceed 0.5 in order to be retained.
The results show that the standardised factor loadings were all higher than 0. Thus, all constructs showed good convergent validity.

Direct effects of psychological contract violation
As shown in Table 3

Mediating the effects of organisational justice
The variance inflation factor (VIF) for each variable was not greater than five, so the multi-collinearity was within the traditionally acceptable level. In Tables 4 and 5, the results of model (1) show that psychological contract violation is significantly positively correlated with exit and neglect behaviours (P ＜ 0.05), and is significantly negatively correlated with voice and loyalty behaviours; thus, hypotheses H1a and H1b are accurate.
Model (2) shows that psychological contract violation is significantly negatively  Table 6 shows that the mediating role of organisational justice accounts for more than 22% of the total effect. It clearly suggests that the transmission mechanism between physicians' psychological contract violations and EVLN behaviours, when physicians' psychological contract violation occurs, is mainly through the perception of organisational justice to change their behaviour choices. Table 4. Mediating regression of procedural justice.

Variables
(1)     Trybon, 2016, 2017) [14,2,4,35,3]. Bunderson (2001) [4] and Trybon (2016, 2017) [35,3] showed that psychological contract violation is positively related to physicians' turnover intention and a high level of fulfilment of their psychological contract provides more motivation to contribute to the mission statement. This results is consistent with social exchange theory (Adams, 1963;Blau, 1964) [43,44] and control theory (Carver & Scheier, 1982) [45], when physicians feel that there is a difference between the content promised by the hospital and the content actually received, from the perspective of the physician, this difference reflects on an imbalance in the social exchange relationship between them and the organisation. Physicians have the motivation to eliminate or reduce this imbalance, including both positive and negative behaviours.
In addition, the actual response of physicians to psychological contract violation is likely to be strongly influenced by the context surrounding the psychological contract  [50,51], and the response of professional employees to perceptions that their organisation is not trying to fulfil the contract is also different (Bunderson, 2001;Trybon, 2016Trybon, , 2017 [4,35,3]. In summary, physicians, also professional employees, interact with an employing organisation both as professionals and employees. So, establishing a good incentive mechanism for physicians requires attention to the role of psychological contract violation. Hu GP. (2013) [52] found that organisational justice is essential to the stability of professional employees. The results of this study also suggest that hospitals should pay attention to organisational justice factors in the development process of hospitals, and build a scientific and reasonable distribution system and

Conclusion
The results of this study demonstrate that physicians' psychological contract violation has a direct impact on physicians' EVLN behaviour, which has a positive effect on constructive behaviour and a negative effect on destructive behaviour. In addition, it suggests that organisational justice has a mediating effect between physicians' psychological contract violation and EVLN behaviour, which accounts for a large proportion of the total effect.

Limitations and future research
This study is not without its limitations, and its results should be interpreted carefully. First, this study is only a study of tertiary public hospitals in Beijing. We can consider factors such as different levels and different regions for further research, and consider physicians from multiple hospitals to draw more general conclusions. Second, the evolution of physicians' behaviours is a dynamic and long-term process. This article only conducted a cross-sectional survey and did not conduct dynamic tracking studies.
In fact, the introduction of public hospital reform policies and the internal reforms of hospitals are more likely to cause changes in physicians' behaviours. It would be more meaningful to analyse the changes in physicians' behaviours before and after reforms to evaluate reform policies. Third, considering that it is difficult to obtain evaluation information from physicians by multiple parties, the effect indicators of this study mainly rely on individual self-evaluation. In the future, information may be collected through multiple channels and methods to ensure comprehensiveness and objectivity.
LJH was responsible for conceptualization, methodology, investigation, validation, formal analysis, data curation, writing-original draft preparation and visualization. JLZ was responsible for conceptualization, methodology, writing-review and editing and supervision. YZ, TC and YFJ was responsible for investigation.

Funding
The research is supported by the National Natural Science Foundation of China (no.71974133, 71573182).

Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Ethics approval
The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Ethics Committee of Capital Medical University (protocol code Z2020SY131, date 2020-11-16). We explained the contents of the investigation to all participants and insured they get informed consent.

Consent for publication
Not applicable. Figure 1 Study Framework