Interested in understanding more about the importance of values and going the extra mile in the NHS? Find out more in a new published paper on ‘Pro-social organisational behaviour of health care workers’. International Journal of Human Resource Management, 24(16), 3115-3130. A full version of this article can be found at


For many years some people have suggested that the NHS works off the goodwill of the millions of people who work in the service, that healthcare workers go the extra mile because of prosocial values around patient care. To test some of these assumptions out we can drawn on the research fields of the psychological contract (Rousseau , 1995) and prosocial organisational behaviour (going the extra mile) (Brief and Motowidlow, 1986).

Rousseau  distinguishes between transactional and relational contracts. The former assuming we are rational and self interested actors and a reciprocal agreement involves good performance for good terms and conditions.  The transactional agreement is not directly with anyone in particular.  The latter assuming that we have a reciprocal agreement with another party. That party is specified clearly, yet the true nature of the contract cannot be fully specified.  The relational contract is particularly important in healthcare as the success of healthcare often depends on individuals spontaneously co-operating with others to deliver excellent patient care, rather than utilising a fully prescribed set of behaviours.

Professor Paula Hyde,  Professor Ruth Boaden and I (2013) explored the psychological contract and prosocial behaviour (going the extra mile) in healthcare in the UK.  We asked clinical and non clinical staff to give an example of a time when they had gone beyond what was expected of them, what had prompted them to go beyond and the perceived impact on patient care.

The most common forms of prosocial behaviour were putting in extra effort (e.g. “working over two sometimes an extra three hours a night”) and helping co-workers (e.g. “nurses still phone me up…its not my job but I’ve got a sympathetic ear and i get involved”).  Interestingly director level respondents were also more likely to say that nothing is beyond in their role!

The reasons for their prosocial behaviour were down to their own attitudes (e.g. “its personally driven”), prosocial patient values (“I am a nurse at heart, I actually think the patient should always be put first”), organisational culture (e.g. “the culture of the organisation means we all pull together to get things done”) and prosocial co-worker values (e.g. “I value the staff and I think things like that go a long way”).  Interestingly clinical respondents were more likely to mention pro-social patient values.

Healthcare workers appeared to consciously choose to go the extra mile because of deep seated values round helping patients and co-workers. This indicates that goodwill in the NHS is important for patient care.

An interesting question is the extent to which the prosocial behaviour aimed at helping patients also enhances organisational performance and targets.  We found in the study that these two aims were not necessarily aligned.

So we cannot prescribe every behaviour necessary in healthcare nor may we want to particularly when people come to work in the NHS with their own set of prosocial patient values.  However sometimes these values override the desire to fulfil performance targets, particularly if a perceived choice has to be made between patient care and targets.

What happens when psychological contracts get breeched?

Work by Bunderson (2001) has explored the nature of ideologies and transactional and relational breeches of psychological contract in healthcare in the US.  He distinguishes professional and administrative ideologies, the former sees the individual as a professional with obligations to fulfil their professional role (e.g. patient care) and the latter sees the individual as an employee obliged to fulfil their role requirements.  Bunderson found administrative breeches to be associated with turnover and professional breeches were associated with performance, patient care and commitment to the organisation.  So when an employing organisation fails to fulfil their administrative role obligations, people tend to respond in self interested ways given the transactional nature of the administrative role.  Professional role obligations appear to be more relational based.  Good relational exchanges foster loyalty, commitment and creativity in exceeding patient needs/expectations. The perception that ones employing organisation is not fulfilling their relational obligations can result in one withholding their contributions.

So this study appears to indicate that relational contracts are critical to the delivery of patient care and organisations must take care not to breech their relational obligations.  If they do they will have to take care in re-negotiating those contracts, because once healthcare workers perceive a potential relational breech they may stop going beyond and withhold good will, which could have an impact on patient experience.

So what does this mean for the future?  How do healthcare workers feel when they transfer over to new providers, no longer working for the NHS?  What impact does this have on their psychological contract? What impact does this have on going the extra mile and good will?

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