Content and violation of the psychological contract among head nurses

Enquadramento: O estudo foca-se no conceito do Contrato Psicológico (CP) na perspetiva de que a perceção das obrigações existentes entre empregador e empregado é construída pelo indivíduo. Objetivos: Identificar o conteúdo do CP dos enfermeiros chefe, identificar a (in) existência de perceção de violação deste contrato e as reações à eventual perceção de violação. Metodologia: Estudo exploratório descritivo, de abordagem qualitativa, que recorreu à entrevista semiestruturada numa amostra de dez enfermeiros chefe. Resultados: Os conteúdos do CP, ou seja, o que os enfermeiros chefe esperam receber do seu empregador, passam pelo reconhecimento profissional, pela satisfação no trabalho, pela progressão na carreira e pela remuneração compensatória. Quanto ao que estão dispostos a oferecer ao empregador, identificou-se a lealdade à hierarquia, à entidade empregadora e à classe profissional, e um desempenho de excelência. Conclusão: Todos os entrevistados percecionaram violação do CP por parte do seu empregador. As principais reações à violação foram: diminuição do empenhamento organizacional, precipitação para a reforma (intenção de abandonar a organização), desmotivação e negação da nova condição profissional.


Introduction
Over the last few years, the healthcare sector has undergone a series of structural, procedural and political transformations.Among these transformations were the adoption of new management models (namely the health business management), the primary healthcare reform and the restructuring of the network of hospital emergency services.In addition to these changes, the professionals' careers have also undergone considerable changes, which can be seen in their reconfiguration.The professional group of Nursing negotiated a new career.This was an arduous and lengthy process that resulted in changes that interfere with the dynamics and stability of the profession and, consequently, its professionals.The concept of Psychological Contract (PC) may be used as a model to explain the employee-employer relationship.The PC concerns an individual's perception of a reciprocal exchange relationship between himself/herself and the employer organisation (Rousseau, 1989(Rousseau, , 1995)), a relationship that is in the eye of the beholder.The idea underlying this contract is that the employees' behaviour towards their employers depends on their belief of whether the employer has been keeping (or not) the promises that were subjectively perceived as having been made to the employee (Conway & Briner, 2005).Therefore, this study aimed to understand the employee-employer relationship using the PC construct in a professional Nursing group of head nurses in an organisation of the Portuguese National Health Service with business management.Head nurses were chosen for this sample given their key roles in healthcare organisations, namely at the middle management level of Nursing teams.The starting point for this study was the change that occurred within the Nursing career and the fact that the category of head nurse is now considered a subsistent category in the new Nursing career.Therefore, this study aimed to understand the implications of that change in employment relationships, particularly at the PC level.For this purpose, the following objectives were set out: a) to identify the contents of the PC established by head nurses with their employers; b) to identify whether head nurses perceived their PC to have been violated; c) to identify which reactions stemmed from this perception of PC violation, in case it happened, and the individual and organisational consequences it will have.

Psychological contract
The concept of PC is accepted as one way to explain the relationship between employee and employer, helping to analyse the relationship between those organisational members.Its importance is clear in the consequences of a perception of violation, which affects aspects of this relationship.This concept is focused on what an individual understands he/she owes the organisation and what he/she expects to get in return.This type of contract is perceptive and idiosyncratic (Rousseau, 1995), and is constructed throughout the employees' professional lives through ongoing interactions with their employers (Rousseau, 1989(Rousseau, , 1995;;Conway & Briner, 2005;Conway & Colye-Shapiro, 2006).The one-sided view of the PC postulates that the individual (employee) is the one developing a contract, which implies an individual belief over the mutual expectations and obligations of the employer-employee relationship in a given context.The one-sided view relates mainly to the employee's perspective of the job and the organisation, namely the expectations and obligations, thereby limiting the PC to an individual perception (Rousseau, 1989(Rousseau, , 1995)).According to Rousseau (1995), the development of this type of contract is associated with the interaction of two key factors: individual factors and organisational factors.Individual factors encompass the processes of encoding and decoding organisational messages, as well as the individual's own inclinations.Organisational factors relate to social clues, that is, information provided by the organisation which may be interpreted as promises and describe its future intentions.Rousseau (1989Rousseau ( , 1995) ) underlines that the PC is unique for each individual (employee); it is a nonwritten agreement between employee and employer, whose terms include perceived mutual obligations that interfere with how the employee relates to his/ her organisation.Therefore, the term PC refers to "an individual's beliefs regarding the terms and conditions of a reciprocal exchange agreement feelings of injustice (Krivokapic-Skoko et al., 2010), decreased organisational citizenship behaviour (Jafri, 2012;Cassar & Briner, 2011), as well as feelings of anger, increased turnover and reduced levels of commitment (Zagenczyk, Gibney, Few, & Scott, 2011;Cassar & Briner, 2011;Thomas, Feldman, & Lam, 2010;Menegon & Casado, 2006).Studies have also shown that PC violation leads to a lack of trust in the organisation (Krivokapic-Skoko et al., 2010;Conway & Briner, 2005), emotional exhaustion (Gakovic & Tetrick, 2003), feelings of revenge and depression (Menegon & Casado, 2006).Authors such as Thomas, Feldman, and Lam (2010) point out the importance of investigating the factors that lead to PC violation in order to control them, or even eliminate them, as they may lead to cascading effects and their consequences may be devastating for the collaborator's performance.Also, in case no intervention occurs to alleviate the problem, the resulting consequences tend to get worse over time, not better.

Psychological contract in Nursing
For years, the Nursing career was regulated by Decree-Law no.437/91 and structured according to different categories: level 1 or level 2 nurse, graduate nurse, nurse specialist, head nurse and nurse supervisor.Levels 1 and 2 nurses, graduate nurses and nurse specialists are responsible for providing direct care to the patients/family/community. Head nurses and nurse supervisors hold management positions within the Nursing teams and, therefore, do not provide direct Nursing care.After the negotiation of the new Nursing career, the previous categories were restructured, namely the category of head nurse and its functional content.In the light of a new career (Decree-Law no.248/2009), this is now considered a subsistent category, which means that when current head nurses retire, no other nurse will be a career head nurse.Within the Nursing profession, it is known that head nurses play a decisive role in team leadership and a major role in how Nursing care is provided to a given population.In this way, this study aimed to identify the state of mind of those leaders within the organisations and the implications for healthcare organisations of those professionals' possible perception of PC violation.According to Hesbeen (2001), the main mission of the head nurse is to focus on his/her between that focal person and another party" (Rousseau, 1989, p. 123) and consists of "individual beliefs, shaped by the organization, regarding terms of an exchange agreement between individuals and their organization" (Rousseau, 1995, p. 9).

Psychological contract breach
The employee's belief that the organisation should keep the promises and commitments both perceived and made is a core aspect of the PC.When a collaborator realises that the organisation did not keep its promises or obligations, then he/she may experience a breach or violation of the PC by the employer (Rousseau, 1995).Therefore, it can be stated that PC breach is a "subjective experience, referring to one's perception that another has failed to fulfil adequately the promised obligations" (Robinson, 1996, p. 576).As such, this PC breach usually creates the perception of an unbalanced social exchange relationship, as the employer does not seem to properly give back to the employee what he/she believes to have given to the organisation.However, a distinction should be made in this domain: breach versus violation.According to Morrison and Robinson (1997), the individual's recognition that the organisation has failed to fulfil one or more obligations inherent in the PC is not enough for a psychological contract to be violated.That recognition is the mere understanding that the promises perceived as made have not been kept, and that perception is described as a PC breach (Morrison & Robinson, 1997).Violation entails the employee's affective and emotional reactions of disappointment, frustration, anger and resentment as a result of his/ her interpretation of the breach and its circumstances.Thus, violation is an "emotional and affective state that may, under certain conditions, follow from the belief that one's organisation has failed to adequately maintain the psychological contract" (Morrison & Robinson 1997, p. 230).The authors highlight that violation is an emotional experience, yet it arises from a cognitive interpretation process.Empirical studies have found PC breach/violation to be related to decreased well-being, negative attitudes towards the job and organisation, and the intention to leave the organisation (Krivokapic-Skoko, O 'Neill, & Duwell, 2010;Chambel & Peiró, 2003).In addition, the perception of PC breach seems to be also related to decreased levels of job satisfaction and increased team members so as to provide them with the best possible conditions to exercise their profession.The key role of the head nurse is to contribute to making healthcare services more efficient.Therefore, they play an important role in planning (establishing goals, planning resources) and controlling health activities and outcomes.On account of this, these professionals' ability to perform such functions with the expected level of commitment from both the organisation and the professionals they lead is questioned.

Research Questions
Research questions were formulated to understand the content of the head nurse's PC, identify whether they perceived any PC breach/violation and what that breach/violation would imply.This is important considering that the failure to fulfil the PC makes professionals lose their trust in the organisations, be dissatisfied towards their jobs and show less commitment to the organisation (Robinson, 1996;Morrison & Robinson, 1997;Jafri, 2012).Bearing in mind the objectives set out, the following research questions were outlined: What are the contents of the PC established by the head nurse with his/her employer?;Do these professionals perceive their PC as having been violated?;What are the implications of the PC violation (if perceived)?

Methodology
This is a qualitative exploratory descriptive study whose locus of study was the group of Healthcare Centres of the Local Healthcare Unit of Alto Minho (Unidade Local de Saúde do Alto Minho -ULSAM, EPE).This Local Unit is a business entity that comprises the hospital centre of Alto Minho (composed of two hospitals) and 13 healthcare centres, covering the district area of Viana do Castelo.The target population consisted of head nurses of all healthcare centres belonging to the Local Healthcare Unit, with only one head nurse per healthcare centre.Only 10 head nurses participated in this study since, when the study was conducted, the head nurses of two healthcare centres were not in office (one due to retirement and the other to service commission, i.e. there was no career head nurse) and the head nurse of another centre was on a long-term sick leave (this head nurse was chosen for the pre-test of the interview script).In view of these study characteristics, the semistructured interview was the preferred technique to collect data.This seemed to be the best solution given the sensitive nature of the questions.After all, participants were asked to assess their feelings towards a set of dimensions associated with their job and employing organisation.To this end, an interview script was prepared and pre-tested (a head nurse of that organisation providing the same type of healthcare was interviewed) to guarantee that participants would fully understand the topic and questions to be asked (Fortin, 1999).Thus, this procedure aimed to clarify the interview's content, making it clearer and more understandable to the target population.Data were collected between February and May, 2011.To this end, permission was obtained from the Board of Directors of the ULSAM, EPE.The head nurses were previously contacted by phone and the interviews were conducted at their work places.All ethical principles for scientific research were considered throughout this study.Participants were ensured data anonymity; they were also ensured that the data obtained would not be used by other people or for any other purpose.At the beginning of each interview, the study and its main objectives were explained in detail.Participants were also asked to give their permission to audio record the interview.The technique of content analysis (Bardin, 1977) was used for data analysis, which allowed for the definition of the thematic areas, categories and subcategories for the subsequent treatment and analysis of the results.Given the reduced number of interviews, no computer software was deemed as necessary to be used.

Results and Discussion
As for the characterisation of the study sample, all the interviewees were female, with a mean age of 50.8 years and an average of 29.6 years of professional practice, which indicates a long professional career.Most of their professional experience was in the area of primary care, although four interviewees also referred to experience in providing differentiated healthcare.Four interviewees had been head nurses for 4.5 years, two for 6 years, one for 9 years and three for more than 10 years.All interviewees held a higher education degree awarded after the completion of the specialised higher education course (curso de estudos superiores especializados), which also granted them the title of nurse specialists in a specific Nursing area.As for their additional training, three nurses also had a post-graduation in management/ administration of healthcare services and one had a Master's degree.In this section, the results obtained in the following identified thematic areas will be presented: Thematic Area I -Content of the head nurses' PC; Thematic Area II -Perception of PC violation; Thematic Area III -Reactions to PC violation.

Thematic Area I: Content of the psychological contract
The analysis of the interviews 'content allowed for the identification of two categories within this thematic area.The first category related to what head nurses expected to receive from the organisation.The second category referred to what they were willing to offer.
As to what they expected to receive, four subcategories were identified: professional recognition, job satisfaction, career progression and a fair compensation.Professional recognition was represented by N4 "(…) considering that I was a substitute head nurse for a long time, when I applied, I became a career head nurse and achieved the deserved legal recognition (…)" (March, 2011).Job satisfaction may be exemplified by N1 "(…) job satisfaction so that all nurses are able to do their job the best they know and can (…)" (February, 2011).Career progression was addressed by N9 "(…) for years, I never thought of progressing in my career, but then I thought I should do it and that's why I applied for head nurse (…) also to become professionally accomplished (…)" (May, 2011).At last, obtaining a fair compensation was also mentioned as something that nurses expected to receive from the organisation.For example, N5 mentioned "(…) the salary is also important when changing category, in a way I also thought of that (…)" (April, 2011).
As for what head nurses were willing to give their employing organisation, four categories stood out: performance of excellence, loyalty to the hierarchy, loyalty to the organisation and loyalty to the professional group.Performance of excellence was exemplified by N4 "(…) when I took office as head nurse, I thought about my responsibilities and how my performance of the role could improve the provision of care to the population (…)" (March, 2011).The loyalty to the hierarchy was illustrated by N5 "(…) our career is one focused on hierarchies and I've always acknowledged and respected them (…)" (April, 2011).As for the loyalty to the organisation, it was identified by N3 "(…) I've always done my best to run this house as if it were my own (…)" (March, 2011) and N4 "(…) when taking office, there's an implicit oath of loyalty to the institution (…)" (March, 2011).The loyalty to the professional group was also evidenced by N4 "(…) I still believe that head nurses are supposed to protect the group (…) if head nurses want to fight for their role, they have to fight for nurses (…)" (March, 2011).Similar to the results obtained by Menegon and Casado (2006), this study demonstrates that head nurses expected to receive from their employers the possibility of developing a career, a rewarding salary and the recognition for their performance.As to what they were willing to offer in return to the organisation, it was observed that they intended to give their best and be loyal to the organisation and the professional group.Data analysis suggests that Rousseau's assumption (1995) that the key issue of the PC is the belief that a promise has been made and something is offered in return, thus forcing the parties to comply with a set of reciprocal obligations, was not effectively observed.This is because the promises made by the organisation were not kept, yet nurses were always willing to give their best in return.

Thematic Area II: Perception of violation of the psychological contract
A key aspect of the PC is the employee's belief that the employing organisation lives up to its promises and commitments.When a collaborator becomes aware that the organisation does not keep its promises or obligations, they experience a contract violation.The head nurses' perception of PC violation is identified based on the distinction between the than the loss felt, it was how the loss occurred that contributed the most to the perception of PC violation.All head nurses mentioned that they had to go through a public tender and demonstrate their skills to then feel that they had lost everything they had achieved.This was also a decisive factor which contributed to make them feel violated in their professional ideology and the future of their professional career.It should also be noted that this loss resulted from a decree-law and not from the effective loss of their capabilities or will to exercise such position.

Thematic Area III: Reactions to the violation of the psychological contract
In general, the literature shows that PC violation brings about serious consequences for both workers and organisations (Gakovic & Tetrick, 2003;Cassar & Briner, 2011;Menegon & Casado, 2006;Jafri, 2012).The analysis of the interviews revealed that the PC of the nurses under study was violated and the consequences of that violation.Thus, two categories were identified in this thematic area: reactions at both the personal and the professional levels.At a personal level, the following subcategories were identified: disenchantment and dullness.Disenchantment with the profession was illustrated by N1 "(…) maybe, if I looked back, I would have embraced what I'm doing now [coordinating a Community Care Unit] (…) without being head nurse, considering that I had to go through a public tender for that (…)" (February, 2011).It should be clarified that a Community Care Unit can be coordinated by someone who is not a head nurse but simply holds the title of specialist.This helps to understand the disenchantment experienced by some nurses under study.Dullness was expressed by N1 "(…) the role of the head nurse was limited (…) I stopped having an active role on the human resources area (…)" (February, 2011).At the professional level, the denial of the new professional status, less commitment and the intention to leave the organisation (request for retirement) were highlighted.The denial of the new professional category (resistance to change and psychological suffering) was evidenced by all interviewees.Fragments of speech perfectly illustrated the difficulty of accepting the new professional status.Thus, N4 stated that "(…) for some reason, I refused to perform tasks other than concepts of breach and violation proposed by Morrison andRobinson (1997), andCassar andBriner (2011), in which PC violation is seen as the emotional and affective state that may, under certain conditions, follow from the belief that one's organisation has failed to adequately maintain the contract.The following subcategories, which allowed identifying the perception of PC violation, were found in the interviews: anger, resentment, spite, sadness, frustration and humiliation.Anger was mentioned by N2 "(…) I'm extremely angered at what happened (…)" (February, 2011).
Resentment was very well identified by N1 "(…) it really hurt to hear the high ranks of the organisation state in public that head nurses no longer exist (…)" (February, 2011).Spite was expressed by N2 "(…) this happened here, at the healthcare centre, in a meeting involving doctors, administrative staff and nursing assistants, and they said: the position of the head nurse no longer exists.I couldn't believe it and said oh my God, what's this!? (…)" (February, 2011).Sadness was mentioned by N6 "(…) I'm a bit sad at how we regressed and how the nursing career has been demoralised (…)" (April, 2011).Humiliation was referred to by N5 "(…) I feel humiliated, I'm not heard in the organisation where I work (…)" (April, 2011), while frustration could be felt in the statements of N8 "(…) nobody mistreated me or hit me, but you just can't imagine the daily frustration (…)" (May, 2011).All head nurses perceived that their PC had been violated.The major manifestations of PC violation were feelings of anger, resentment and frustration, which were also identified in a study conducted by Zagenczyk et al. (2011).When a person achieves a certain status within a professional group, they expect to be treated accordingly.This was identified in this study, as all head nurses sought to build a professional career that would have them be taken into consideration by the organisation.The way that they felt they were treated (the lack of respect for their professional path, effort and commitment) were the main factors that made them feel defrauded and, consequently, perceive their PC has having been violated.According to them, their hierarchical superiors' disrespect, particularly their public demonstration of it, made them feel fatally wounded.One may say that these nurses felt emotionally exhausted, as identified by Gakovic and Tetrick (2003).It is, therefore, considered that, more

Conclusion
This study aimed to understand the contents of the PC, as well as identify if a perceived violation of that contract existed and its implications on the dynamics of the relationship between the head nurses and their employing organisation.The results obtained allowed to identify and understand the spectrum of experiences and hardships or opportunities encountered by the head nurse at a given stage of his/her professional career, as well as how he/she processed such experiences.It was found that the content of the head nurses' PC focused on their relationship of give-and-take with the organisation and encompassed two dimensions: what head nurses expected to receive and what they were willing to give to the institution.Regarding what they expected from the organisation, the following aspects were identified: professional recognition, job satisfaction, career development and fair compensation.As to what they were willing to give, the following aspects were identified: loyalty to the hierarchy, loyalty to the organisation, performance of excellence and loyalty to the profession, which leads to the assumption that the identification with a cause is higher than self-interest.All interviewees believed that their employing organisation had violated their PC.The main consequences from this perception were evidenced through feelings of resentment, spite, sadness, anger, frustration and humiliation.Concerning the main reactions to PC violation, disenchantment with the profession, dullness (psychological suffering), rushing into retirement (intention to leave the organisation), less commitment, denial of the new professional status and lack of motivation were identified.The perception of PC violation appeared to be more strongly related to how the process of adjustment to the new category was conducted than to the change itself, which was caused by the change introduced with the new career.It was, therefore, stressed that the changes in the career should be effectively managed by the hierarchical superiors, since all interviewees stated that one of the major thrusts of their performance was the loyalty to the hierarchy and that they felt abandoned and/or disrespected by their superiors.In accordance with the results obtained, some possibilities for future research open up, such as the ones performed by head nurses and never gave that up (…)" (March, 2011).N6 pointed out that "(…) I explained the team that I would keep my role of head nurse until the new legislation was issued (…)" (April, 2011).The less organisational commitment was evidenced by N2 "(…) before, I would take work home, because I couldn't focus at work, now I stopped doing that (…)" (February, 2011).N3 added that "(…) i give my name because they need someone with my qualifications [for the formal establishment of the comunity care unit] but that's it, i have no motivation; I just don't care anymore (…)".Two head nurses mentioned the intention to leave the organisation and the requests for early retirement, arguing that "(…) I won't deny that I'm waiting for retirement, I filled out the request, because the changes we're experiencing rushed my retirement process (…)" (March, 2011) -N3, and that "(…) this whole situation made me think about the possibility of early retirement so that I can move away from the job (…)" -E5 (April, 2011).These results were in line with other studies on the implications of PC violation (Krivokapic-Skoko et al., 2010;Chambel & Peiró, 2003).It seems that the perception of PC violation in this sample is strongly related to how the process of adjustment to the new category was carried out.It should be noted that more than the changes themselves, the way the process was carried out was the major cause of perceived PC violation.Rousseau (1995) points out that many of the causes of PC violation are related to changes of hierarchical superiors in the organisation.The data obtained and analysed confirm that this was partly what happened in the organisation under study.Although the circumstances were not fully identical to the ones pointed out by the author, the assumptions were considered to be present.Head nurses identify the organisation as the Nursing management board, thus the nurse director may be considered the direct representative of the organisation.Thus, in the case of the organisation under study, the way the whole process was conducted by the board, in particular the nurse director, was directly responsible for the feelings of PC violation experienced.This is because the nurse director was the one responsible for leading the whole process of transition to the new category and did not respect the ideological framework of the profession.
studying the content of these professionals' PC in view of the new professional status.Taking into consideration the context of the study (Local Health Unit of Alto Minho, consisting of 13 healthcare centres and 2 hospitals), the study of the PC of primary care head nurses is recommended.This suggestion is based upon the findings of Rousseau (1995) that the context of professional practice is one of the foundations of the PC.