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Social Science & Medicine 68 (2009) 894–902

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Social Science & Medicine

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The relational underpinnings of quality internal auditing in medicalclinics in Israel

Abraham Carmeli*, Malka ZisuBar-Ilan University, Ramat-Gan, Israel

a r t i c l e i n f o

Article history:Available online 17 January 2009

Keywords:Internal auditingIsraelHealthcare organizationsPsychological safetyTrustPerceived organizational support

* Corresponding author. Graduate School of BusinUniversity, Economics Building, Room 459, Ramat-Gan

E-mail address: carmelia@mail.biu.ac.il (A. Carmel

0277-9536/$ – see front matter � 2008 Elsevier Ltd.doi:10.1016/j.socscimed.2008.12.031

a b s t r a c t

Internal auditing is a key mechanism in enhancing organizational reliability. However, research on theways quality internal auditing is enabled through learning, deterrence, motivation and processimprovement is scant. In particular, the relational underpinnings of internal auditing have beenunderstudied. This study attempts to address this need by examining how organizational trust, perceivedorganizational support and psychological safety enable internal auditing. Data collected from employeesin medical clinics of one of the largest healthcare organizations in Israel at two points in time six monthsapart. Our results show that organizational trust and perceived organizational support are positivelyrelated to psychological safety (measured at time 1), which, in turn, is associated with internal auditing(measured at time 2).

� 2008 Elsevier Ltd. All rights reserved.

Internal auditing is an important organizational process.However, it becomes even more critical in organizations thatoperate under very trying conditions such as healthcare organiza-tions that need to ensure high safety and reliability (van Herk,Klazinga, Schepers, & Casparie, 2001; Weick & Sutcliffe, 2001). Thisis especially true when one considers the Institute of Medicine’sstudy ‘To Err is Human,’ which indicated that at least 44,000 andpossibly as many as 98,000 Americans die each year as a result ofmedical errors, and highlighted the impact of these mistakes onhuman life (Kohn, Corrigan, & Donaldson, 2000). Although thesefigures have been the topic of some debate, ‘‘healthcare providersagree that more needs to be done to promote patient safety’’(Abbott, Weber, & Kelley, 2005, p. 1107).

We suggest that quality internal auditing is an importantmechanism for improved healthcare services and increased patientsafety because it provides the organization with critical data andevidence on how things are done and what needs to be improved.This is because internal auditing enables careful reporting andanalysis of mistakes and near-misses, thus cultivating learning fromfailures to increase safety (Weick & Sutcliffe, 2001). However,despite growing scholarly recognition of its importance, littleresearch has been directed to factors that enable quality internalauditing. We know little about the relational underpinnings[manifestations of social exchange (perceived organizational

ess Administration, Bar-Ilan, Israel. Tel.: þ972 3 5318917.

i).

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support, organizational trust and psychological safety) that enablework activities] of internal auditing. While people report that theyvalue auditing, they prefer not to be under scrutiny because auditsoften produce negative feelings such as distress, threat, anddetachment, and even bitterness, resulting in resistance anduncooperative behaviors that could damage the organization. Thisis vital because studies pointed to the importance of speaking upand discussing potential threats to patient safety to increase reli-ability (Sutcliffe, Lewton, & Rosenthal, 2004).

Hence, theoretically and practically we need to develop qualityinternal auditing that employees will view as a helpful andcontributing activity, as well as explore the conditions that mayalleviate employees’ concerns, negative feelings and defensivereactions to internal auditing activities. Despite Eden and Moriah’s(1996) endeavor to conceptualize quality auditing as a constructwhose hallmarks are learning, deterrence, motivation and processimprovement, only rare attempts have been made to examine theirformulation in healthcare settings. Furthermore, becauseemployees often develop excessive concerns about being underscrutiny it is important to study the relational foundations ofauditing activities. However, research has yet to unravel relationalfactors that may lessen employees’ excessive concerns and negativefeelings and reactions in this situation.

We propose a model of quality internal auditing that may befacilitated through three relational aspects: perceived organiza-tional support, organizational trust, and psychological safety. Weanalyzed data from a series of pilot studies and surveyed datacollected at a six-month interval from 191 employees in medicalclinics at a large healthcare provider in Israel.

A. Carmeli, M. Zisu / Social Science & Medicine 68 (2009) 894–902 895

Internal auditing

Internal auditing is a process that examines and evaluates thefunctioning of an organization (Eden & Moriah, 1996, p. 263) andcompares actual performance against standards or expectations,based on relevant indices, to improve the organization’s achieve-ments (Globerson & Globerson, 1990). Internal auditing comprisesa comprehensive plan and methods aimed at helping themanagement team to enhance organizational control (Scott,Mannion, Davies, & Marshall, 2003).

Internal auditing is an essential mechanism that providesprotection against fraud and errors that may not be traced withoutit, assures compliance with policy and practice, and helps enhanceefficiently and effectiveness. As Weick and Sutcliffe (2001) put it,‘‘moving toward a more mindful system and higher reliability is toenlarge what people monitor, expect, and fear’’ (p. 91). Research hasshown its importance for enhancing organizational outcomes ofboth business firms (Carmeli & Tishler, 2004a) and public sectororganizations (Carmeli & Tishler, 2004b).

Quality internal auditing is characterized by four importantfeatures: learning, deterrence, motivation and process improve-ment (Eden & Moriah, 1996). In complex organizations such ashealthcare service providers there is a need to pinpoint andexamine a broad swath of activities to (1) instruct the organ-ization’s members how to better execute their jobs by pointing outweaknesses (i.e., learning), (2) deter members from actions thatmay damage the organization (i.e., deterrence), (3) increasemembers’ motivation by showing that the goal of the audit is toimprove the efficiency and effectiveness of the organization (i.e.,motivation), and (4) increase the likelihood that appropriateactions will be taken in relation to goal setting and accomplishment(i.e., process improvement) (Eden & Moriah, 1996).

Relational underpinnings of internal auditing

Despite the important benefits of internal auditing for both theindividual and the organization, being under scrutiny mayengender negative emotional reactions. Like other activities, auditsare inherently relational, as different stakeholders (e.g., managers,peers, auditees, and auditors) interact prior, during and after theprocess.

Here we examine the impact of three relational factors that maylead employees to view the internal auditing as an importantmechanism in enhancing organizational outcomes: organizationaltrust, perceived organizational support and psychological safety.

Psychological safety and internal auditingPsychological safety describes the perception that ‘‘people are

comfortable being themselves’’ (Edmondson,1999, p. 354) and ‘‘ableto show and employ one’s self without fear of negative conse-quences to self-image, status, or career’’ (Kahn, 1990, p. 708). Whenmembers are comfortable with expressing themselves and feel thatit is safe to take interpersonal risks in the workplace without fearingnegative consequences (Edmondson, 2004; Kahn, 1990) they arelikely to be more willing to engage and cooperate with auditingactivities. This is because when members sense that they arepsychologically safe they will be more willing to learn from both theauditors’ expertise and the audit findings since they are less con-cerned about the potential negative consequences on their imageand status in the organization. Auditing activities are seen as helpingthem unravel problematic processes because they give membersa considerable learning opportunity by exposing specific defects andproviding recommendations and solutions (Eden & Moriah, 1996).

Psychological safety also contributes to members’ view ofauditing as deterrence. Deterrence is intended to prevent an

organizational member from transgressions through threat ofsanctions. At the individual level, deterrence refers to a directresponse to a specific individual’s misbehavior in an attempt to deterhim or her from repeating similar patterns of behaviors in the future.However, deterrence is not about punishment (Eden & Moriah,1996)as the auditing is not aimed to punish organizational members but tohelp them avoid and prevent repeated mistakes and transgressions.

Members who feel psychologically safe are more motivated toseek feedback on their work (Edmondson, 2004). Psychologicalsafety is a key facilitator in motivating people to embrace auditingactivities because they are able to engage in learning behaviors andprocess improvements by raising concerns and talking about thingsopenly. Conversely, such motivation, learning and processimprovements are obstructed when people experience interper-sonal threats since they develop anxiety regarding potentialnegative implications and tend to rely on their ‘defensive routines’(Edmondson, 2004). Hence:

Hypothesis 1. Psychological safety will be positively associatedwith quality internal auditing characterized by learning, deter-rence, motivation and process improvement.

Trust and psychological safetyTrust is defined as one’s expectations, assumptions, or beliefs

about the likelihood that another’s future actions will be beneficial,favorable, or at least not detrimental to one’s interests (Robinson,1996, p. 576). Trust is a core relational construct which is oftenconceptualized in terms of one’s perceived risk of vulnerabilitywithin a connection (Rousseau, Sitkin, Burt, & Camerer, 1998). Ina relational context trust influences each individual’s behaviorstoward the other (Deutsch, 1958; Robinson, 1996). Thus, trust isconceptualized as ‘‘the willingness of a party to be vulnerable to theactions of another party’’ (Mayer, Davis, & Schoorman, 1995, p. 712)and an expression of confidence by a party that his or her vulner-ability will not be exploited and that he or she will not be harmed bythe behaviors or actions of the other party (Jones & George, 1998).

Kramer (1999) identified two rational and relational models ofchoice to trust another party. The rational model describes a calcu-lative orientation where one party decides to trust another becauseof the advantages of such an action. The relational model charac-terizes a social orientation where people consider social aspects andmake more intuitive decisions whether to trust or not to trust theother (Kramer, 1999). Although both trust and psychological safetyinvolve perceptions about vulnerability and making choices tominimize negative consequences in a relationship, they areconceptually distinct (Edmondson, 2004). First, the object of focus isdifferent. When discussing trust, the object of focus is on others;namely one is giving the other the benefit of the doubt and placingtrust in him or her, while psychological safety is about the self andthe extent to which others will give you the benefit of the doubtwhen, for instance, you have made an error (Edmondson, 2004).Second, whereas trust pertains to anticipated consequences acrossa wide temporal range, including the relatively distant future,psychological safety concerns relatively short-term interpersonalconsequences that an individual expects from engaging in a specificaction such as reporting errors (Edmondson, 2004).

Trust is an important catalyst in developing a sense of confi-dence that an individual or group of people will not embarrassed,rejected, or punished for speaking up. This sense of confidence orthe perception of being psychologically safe stems from relation-ships characterized by a high level of trust (Edmondson, 1999).Empirical studies show consistently that interpersonal trustaugments feelings of psychological safety (Edmondson, 1999; Kahn,1990). What has been less investigated, however, is how trust inone’s employer fosters psychological safety. Building on previous

A. Carmeli, M. Zisu / Social Science & Medicine 68 (2009) 894–902896

research on interpersonal trust, we posit that one’s trust in anemployer is likely to facilitate the belief in being psychologicallysafe to speak up without excessive concerns about jeopardizingstatus, image and career. This is because trust diminishes thelikelihood of breach of psychological contract (Robinson, 1996). Weargue that trust is a key facilitator in the development of one’sbeliefs about the terms and conditions of a reciprocal exchangeagreement between individual and employer (i.e., psychologicalcontract) (Rousseau, 2005). In a psychological contract employeesdevelop beliefs about what they are entitled to receive, or shouldreceive, because they perceive that their employer made suchpromises. Thus, when one trusts his or her employer that he or shewill not be embarrassed or lose status when speaking up or makinga mistake, a sense of psychological safety is developed. Hence,

Hypothesis 2. Trust in one’s employer will be positively related topsychological safety.

Perceived organizational support, organizational trust, andpsychological safety

Many organizations do not only fail to engage in assessingdeviations from norms and expectations but they also do not reapthe full benefits of learning from their own mistakes. A key mana-gerial challenge is to cultivate a supportive context so people will beencouraged and sense they are provided with the support needed toinstill a sense of trust and feel psychologically safe to speak out andthat their competencies are valued and appreciated. Edmondson(2004) argued that when members enjoy a supportive organiza-tional context, psychological safety is fostered because access toresources and information is likely to reduce insecurity anddefensiveness in a team, such as concerns about unequal distribu-tion of resources within the organization and between members.

The concept of perceived organizational support (Eisenberger,Cummings, Armeli, & Lynch, 1997; Eisenberger, Huntington, Hutch-ison, & Sowa, 1986; Rhoades & Eisenberger, 2002) also sheds light onthe support–psychological safety relationship. Perceived organiza-tional support posits that employees develop general beliefs con-cerning the extent to which their organization values and appreciatestheir contribution and cares about their well-being. Employeesreciprocate perceived organizational support with greater workeffort, job satisfaction, organizational affective commitment, lowlevels of voluntary quitting, and positive work behaviors (seeRhoades & Eisenberger, 2002). Three psychological processesunderlie perceived organizational support (Eisenberger et al., 1986;Rhoades & Eisenberger, 2002). First, employees reciprocate perceivedorganizational support with a greater sense of obligation andcommitment to act in a way that contributes to better organizationalfunctioning. Second, perceived organizational support signifiescaring, approval and respect through which an individual’s socio-emotional needs are fulfilled. This, in turn, leads individuals toincorporate organizational membership and role status into theirsocial identity, and thereby develop affective commitment towardthe organization. Third, perceived organizational support augmentsbeliefs that the organization recognizes and rewards employees whoexhibit high performance (i.e., performance-reward expectancies).

Consistent with these psychological processes, we argue thatwhen employees believe that their competencies are valued andappreciated by the organization, they are likely to sense trust andfeel psychologically safe to raise issues and have their voice heardabout problems in the organization without fearing that theirstatus or image will be damaged. In addition, when employeeshold a general belief that their organizations care about theirsocio-emotional needs, they are likely to trust the organizationand feel confident that the organization recognizes the need tospeak up; they thus feel safe and not embarrassed because of suchactions. Finally, when employees believe the organization has

a performance-reward mechanism, they will tend to perceive thatit is psychologically safe to take risks and speak up because suchactions are appreciated and rewarded. Thus,

Hypothesis 3a. Perceived organizational support is positivelyassociated with organizational trust.

Hypothesis 3b. Perceived organizational support is positivelyassociated with psychological safety.

The mediating role of psychological safetyResearch and theory suggest that psychological safety is an

intervening variable between both trust and supportive contextand learning outcomes (Edmondson, 1999, 2004). Drawing on thisline of research and thinking, we argue that the relationshipbetween both trust and support and auditing quality is betterunderstood through psychological safety. This is because both trustand support are initial catalysts for individuals to embrace auditingactivities and cooperate with them. Psychological safety is a social-psychological mechanism that encourages or discourages individ-uals to engage in auditing activities and feel comfortable withexposing and putting themselves under scrutiny.

In a study about learning from failures in hospitals, Tucker andEdmondson (2003) found that in many cases, members are notencouraged to talk about failures. As one nurse noted, ‘‘I do not feelthat my voice is heard. Often I am discouraged, so I don’t share myideas. Where would my ideas go? We are not asked for input’’(Tucker & Edmondson, 2003, p. 69). These are responses ofmembers who do not feel their organization is interested in theiropinion or experience, thus inhibiting the development ofpsychological safety and, in turn, the likelihood of engaging andcooperating with auditing activities.

When employees trust their employer they are likely to feel safeto put themselves under scrutiny, because they understand whatthey are entitled to expect from the organization they work for.When employees can put their trust in the organization they arelikely to develop expectations that their status and image will notbe damaged because of speaking up and cooperating with the audit.

Consistent with Edmondson’s (1999, p. 357) reasoning thatpsychological safety serves ‘‘as a mechanism translating structuralfeatures into behavioral outcomes’’, we posit that psychologicalsafety is an intervening variable in the relationships between bothtrust and perceived organizational support and quality internalauditing. Hence,

Hypothesis 4a. Psychological safety will mediate the relationshipbetween perceived organizational support and quality internalauditing.

Hypothesis 4b. Psychological safety will mediate the relationshipbetween trust and quality internal auditing.

Methods

Overview

This study attempts to theoretically develop and empiricallyexamine a 3-pronged model of relational underpinnings – organi-zational trust, perceived organizational support and psychologicalsafety – as regards internal auditing. Specifically, we develop andtest a model in which psychological safety mediates the relation-ship between both organizational trust and perceived organiza-tional support and quality internal auditing. Because internalauditing is likely to play a critical role in increasing patient safety,we conducted our study on employees who work in medical clinicsand provide daily medical services in a large healthcare

A. Carmeli, M. Zisu / Social Science & Medicine 68 (2009) 894–902 897

organization in Israel in 2006. This organization provides health-care services to about 3.8 million customers, which is more thanhalf of the population of Israel. Its services are delivered througha nationwide network of 14 hospitals, 1300 clinics, 400 pharmacies,37 children’s health centers and 32 women’s health centers. Theorganization employs about 32,000 people, including 9000 physi-cians, 10,000 nurses, 1200 pharmacists, and over 4000 people inlaboratory, administrative and maintenance positions.

Sample and procedure

Prior to administering our survey, we contacted the Director ofHuman Resource Management at the organization and asked forpermission to conduct our study. We held several meetings withthe heads of the organization and clinic heads in which weexplained the importance of auditing in healthcare settings. Wemade it clear that the goal of the study was to explore relationalfactors that affect the way employees view auditing activities.

Upon approval, we first attempted to validate our survey usinga focus group of 15 graduate students in management. Thesestudents were given explicit information about the study goals,constructs and measurement. We asked each student to carefullyread the measurement items and indicate whether they were clearand to what extent each item reflected the corresponding measuresand their dimensions. Next, we asked employees who worked inthe auditing department as well other senior members of thehealthcare organization to follow the same procedure. This two-step process yielded some minor refinements which were incor-porated into the final survey.

We surveyed participants twice over a 6-month period. Wedistributed the first survey on site at Time 1 (T1), to 412 employeeswho were selected at random. The organization HR managerprovided us with an alphabetical list of 1235 employees. We thenselected each third member on the list. In this part of the survey, wecollected data on the three relational factors: trust, perceivedorganizational support and psychological safety. To encourageparticipation we promised full confidentiality and gave eachemployee an envelope with which he or she could return thesurvey to us on site without risk of disclosure. Two hundred andfive responded, yielding a 50 percent response rate.

The second survey, at Time 2 (T2), was administered 6 monthslater to the 205 respondents of the first survey. We asked partici-pants to complete the second part of the survey which containedquestions on quality internal auditing and demographic informa-tion. Those who did not return the survey on site were senta follow-up letter two weeks later and a copy of the survey,encouraging them to complete the survey and return it to us ina self-addressed, stamped envelope. Overall, we received matchedsurveys at T1 and T2 from 191 respondents (a response rate of 46%).The participants did not differ from non-respondents in terms ofage or tenure in the organization (p> .10).

Seventy-six percent were women. The average age of theparticipants was 40.59 years (S.D.¼10.24), their average full-timework experience was 13.40 years (S.D.¼ 9.24). The respondentscame from various professions: occupational therapists (5 percent),physicians (25 percent), nurses (20 percent), medical administra-tors and clerks (39 percent), and clinical support employees(11 percent).

Measures

Quality internal auditingThis measure draws upon a conceptualization of internal

auditing defined by learning (the audit should teach organizationmembers how to improve their performance by clarifying points

and teaching auditees new lessons), deterrence (among otherthings, the audit is designed to deter improper acts), motivation(because most people do not like to be subjected to criticism, theaudit should be perceived as a tool designed to motivate auditees toimprove organizational effectiveness and efficiency), and processimprovement (audits increase the probability that faulty workprocesses will be revised and corrected) (Eden & Moriah, 1996). Weadapted 27 items, shown in Appendix A, from the scale developedand validated by Penini (2006). Six items measured auditing aslearning, eight items measured auditing as deterrence, eight itemsmeasured auditing as motivation, and five items measured auditingas process improvements. Responses were on a five-point scale(ranging from 1¼ ‘not at all’ to 5¼ ‘to a large extent’). We consid-ered the construct of internal auditing as a second-order latentvariable consisting of four latent variables: learning (Cronbach’salpha¼ .89), deterrence (Cronbach’s alpha¼ .92), motivation(Cronbach’s alpha¼ .93), and process improvement (Cronbach’salpha¼ .83). The Cronbach’s alpha for the second-order latentmeasure of quality internal auditing was .93.

Perceived organizational supportWe used 7 items from the measure of perceived organizational

support developed and employed by Eisenberger et al. (1997).Respondents were asked to assess on a five-point scale (rangingfrom 1¼ ‘not at all’ to 5¼ ‘to a large extent’) the extent to which theorganization provides support for and cares for its employees.Sample items are: ‘‘The organization values the employees’contributions’’ and ‘‘The organization supports employees’ deci-sions and actions.’’ The Cronbach’s alpha for this measure was .84.

Organizational trustWe used the 7-item scale developed and validated by Robinson

(1996) to measure employees’ trust in the employer (organization).Respondents were asked to assess on a five-point scale (rangingfrom 1¼ ‘not at all’ to 5¼ ‘to a large extent’) the extent to whichthey trusted their organization. Sample items are: ‘‘I believe myemployer has high integrity’’, and ‘‘I can expect my employer totreat me in a consistent and predictable fashion’’. The Cronbach’salpha for this measure was .88.

Psychological safetyThis measure assesses the extent to which a member of an

organization feels psychologically safe to take risks, speak up, anddiscuss issues openly. We used the 7-item scale of psychologicalsafety developed and validated by Edmondson (1999). Sampleitems are: ‘‘If you make a mistake in this organization, it is oftenheld against you’’ (reverse-scored), and ‘‘Members of this organi-zation are able to bring up problems and tough issues.’’ Items wereall anchored on a five-point scale ranging from 1¼ ‘not at all’ to5¼ ‘to a large extent’. The Cronbach’s alpha for this measurewas .90.

We factor analyzed all items measuring perceived organiza-tional support, trust, and psychological safety. The results producea 3-factor solution. The first factor, psychological safety, had aneigenvalue of 4.47 and explained 23.53% of the variance. The secondfactor, organizational trust, had an eigenvalue of 4.36 and explained22.94 of the variance. The third factor, perceived organizationalsupport, had an eigenvalue of 3.06 and explained 16.10 of thevariance.

Data analysis

To test the research model presented in Fig. 1, Structural Equa-tion Modeling (SEM) (Bollen, 1989) was performed using AMOS 7.In order to assess the fit of the research model in Fig. 1, we used

Learning

Motivation

ProcessImprovement

Deterrence

PsychologicalSafety

R2 = .66

InternalAuditingR2 = .43

TrustR2 = .66

PerceivedOrganizational

Support .48**

.33**

.65**

.73**

.86**

.68**

.89**

.56**

Fig. 1. Results for the hypothesized research model. Oval shows unobserved variables. Statistics are standardized parameter estimates. **p< .01.

A. Carmeli, M. Zisu / Social Science & Medicine 68 (2009) 894–902898

several goodness-of-fit indices as suggested in SEM methodologysuch as chi-square statistics divided by the degree of freedom (c2/df); Relative Fit Index (RFI), Normed Fit Index (NFI), Comparative FitIndex (CFI), Tucker–Lewis coefficient (TLI) and Root Mean SquareError of Approximation (RMSEA). As suggested in the SEM litera-ture (Kline, 2005), the following criteria for goodness-of-fit indiceswere used to assess the model-fitting: c2/df ratio is recommendedto be less than 3; the values of RFI, NFI, CFI, and TLI are recom-mended to be greater than .90; RMSEA is recommended to be up to.05, and acceptable up to .08.

Results

Descriptive statistics and correlations among the researchvariables are presented in Table 1. Cronbach’s alphas for theresearch variables ranged from .84 to .93. The results in Table 1indicate that both perceived organizational support and organiza-tional trust were positively related to psychological safety (r¼ .66,p< .01; r¼ .59, p< .01, respectively), and that there was a positiveand significant relationship between psychological safety andinternal auditing (r¼ .62, p< .01).

Test of the research model and hypotheses

We used SEM (Bollen, 1989) to estimate the research model, as itenables the estimation of multiple associations, incorporation ofsimultaneously observed and latent constructs in these associa-tions, and accounts for the biasing effects of random measurementerror in the latent constructs (Medsker, Williams, & Holahan, 1994).Considering our sample size, however, we used perceived organi-zational support, organizational trust, and psychological safety asobserved variables and internal auditing as a latent variable con-sisting of four observed variables: learning, process improvement,motivation, and deterrence. The model is presented in Fig. 1.

Table 1Means, standard deviations and correlations.

Mean S.D. 1

1. Organizational trust 3.85 .69 –2. Perceived organizational support 3.58 .75 .56**3. Psychological Safety 3.50 .76 .59**4. Quality Internal Auditing 3.46 .65 .41**5. Auditing-Learning 3.32 .81 .32**6. Auditing-Motivation 3.51 .81 .35**7. Auditing-process improvement 3.47 3.85 .41**8. Auditing-Deterrence 3.55 3.58 .32**

N¼ 191, two-tailed test.Reliabilities are in parentheses on the diagonal.**p< .01.

Model comparisons and hypothesis testsTraditional guidelines as outlined by Baron and Kenny (1986)

and more recently modified by Kenny, Kashy, and Bolger (1998)may not be suitable for testing mediation when using SEM (seeJames, Mulaik, & Brett, 2006; Schneider, Ehrhart, Mayer, Saltz, &Miles-Jolly, 2005). Thus, we tested the hypothesized mediatingrelationships through a series of nested model comparisons forwhich the results are shown in Table 2.

Our baseline model is the hypothesized model, where wespecified paths from perceived organizational support to bothorganizational trust and psychological safety, from organizationaltrust to psychological safety, and from psychological safety tointernal auditing. The results in Table 2 show that the model did notfit the data well (chi-square¼ 38.8, df¼ 13; NFI¼ .95, CFI¼ .96;TLI¼ .92; RMSEA¼ .099).

Against the baseline model, we tested two nested models(Models 1 and 2). In Model 1, we added a direct path from perceivedorganizational support to internal auditing. Model 2 was alsoidentical to the baseline model, except for the addition of pathsfrom perceived organizational support to internal auditing andfrom organizational trust to internal auditing. The results in Table 2indicate that the two nested models fit the data relatively well.However, despite these goodness-of-fit indices, only in Model 1, theadditional path (from perceived organizational support to internalauditing) was significant (.27, p< .01). The additional path in Model2 from organizational trust to internal auditing was not significant(.01, p> .10). Based on the principle of model parsimony, weconcluded that Model 1 was the most parsimonious because allpaths were significant and it showed good fit with the data.

Fig. 2 presents the results of the revised model (Model 1), sup-porting Hypothesis 1 which posited that there would be a positiverelationship between psychological safety and internal auditing(.48, p> .01). In support of Hypothesis 2, we found a positiverelationship between organizational trust and psychological safety

2 3 4 5 6 7

–.66** –.57** .62** –.49** .56** .81** –.51** .57** .87** .60** –.48** .55** .89** .65** .77** –.47** .41** .79** .50** .59** .62**

Table 2Comparisons of structural equation models.

Model and Structure c2 df Dc2 RMSEA NFI CFI TLI

Baseline Model: POS / OT / PS / Auditing and POS / PS 38.8 13 .099 .95 .96 .92Model 1: POS / OT / PS / Auditing and POS / PS, POS / Auditing 26 12 12.8** .076 .97 .98 .96Model 2: POS / OT / PS / Auditing and POS / PS, POS / Auditing, OT / Auditing 26 11 0 .082 .97 .98 .95

POS¼ perceived organizational support; OT¼organizational trust; PS¼ psychological safety.In all models the control variables were not included.**p< .01.

A. Carmeli, M. Zisu / Social Science & Medicine 68 (2009) 894–902 899

(.33, p< .01). Hypotheses 3a and 3b positing that perceived orga-nizational support would be positively associated with both trustand psychological safety were also supported (.56, p> .01; .48,p> .01, respectively). The results did not support Hypothesis 4a,which posited that psychological safety would mediate the rela-tionship between perceived organizational support and internalauditing because the path between perceived organizationalsupport and internal auditing remained significant (.27, p< .01).Finally, the findings supported Hypothesis 4b, which posited thatpsychological safety would mediate the relationship betweenorganizational trust and internal auditing, because the pathbetween trust and internal auditing was not significant (.01,p> .10). The multiple squared correlation coefficients (R2s) fororganizational trust, psychological safety, and internal auditingwere .56, .66 and .59, respectively.

We tested whether the respondents’ gender, age, education andjob type (physician, nurses, etc.) accounted for variation in qualityinternal auditing. The results indicated that none of these controlshad a significant impact on auditing quality (p> .10).

Discussion

This study examined the relational underpinnings of internalauditing that may increase patient safety in healthcare settings. Weproposed and tested a model that linked three relational factors –organizational trust, perceived organizational support andpsychological safety – to internal auditing. The findings show that1) both perceived organizational support and organizational trustare positively related to psychological safety, 2) psychologicalsafety is significantly associated with quality internal auditing,3) there is direct and indirect relationship (through psychologicalsafety) between perceived organizational support and qualityinternal auditing, and 4) there is an indirect relationship (throughpsychological safety) between trust and quality internal auditing.

Internal auditing is an important process for improving orga-nizational outcomes, and is notably critical in healthcare settings(Black & Thompson, 1993; van Herk et al., 2001). However, researchhas also pointed to the negative reactions people often develop

PsychologicalSafety

R2 = .66

TrustR2 = .56

PerceivedOrganizational

Support .48**

.33**

.4.56**

.27**

Fig. 2. Results for a revised model (Model 1). Statistic

toward auditing activities. This study sheds light on the relationalunderpinnings of an understudied phenomenon in organizationand management science – internal auditing in organizations.Specifically, our study contributes to a better understanding of howrelational factors affect employees’ perceptions of the internalauditing in their organization, opening up ways by which organi-zations can alleviate excessive concerns associated with beingunder scrutiny.

This first attempt to better understand how quality internalauditing is enabled in healthcare organizations has major impli-cations for healthcare systems that work in trying conditions wheremedical errors can result in severe consequences to human life.Specifically, our study offers a new theoretical lens for ensuringhigh level patient safety and reliability in healthcare organizations(van Herk et al., 2001; Weick & Sutcliffe, 2001). Although we did notexamine the effect of internal auditing on patient safety directly it isimplicit in our study that quality internal auditing is crucial forpromoting patient safety, a key problem healthcare organizationface on a daily basis (Resar, 2006). In so doing, we address the callto further study how patient safety can be enhanced (Abbottet al., 2005).

Another primary contribution of this study is explicating andempirically examining the role of psychological safety in shapingemployees’ perceptions of internal auditing as a quality process oflearning, deterrence, motivation and process improvement. Theliterature mentions that when employees feel comfortable toexpress themselves and speak up openly, behaviors such as inno-vation and learning are facilitated (Edmondson, 2004). Yet virtuallyno attention has been devoted to understanding the relationshipbetween psychological safety and internal auditing. Our studyextends research on psychological safety and shows that it is animportant factor influencing employees’ perceptions of internalauditing as an important activity in terms of learning, deterrence,motivation and improvement of work processes. This suggests thatwhen auditees are able to take a stand without excessive fear ofnegative consequences to self-image, status, or career, they aremore likely to develop less defensive or resisting reactions towardauditing. Our findings show that when employees feel that they are

Learning

Motivation

ProcessImprovement

Deterrence

InternalAuditingR2= .59

8**

.73**

.86**

.68**

.89**

s are standardized parameter estimates. **p< .01.

A. Carmeli, M. Zisu / Social Science & Medicine 68 (2009) 894–902900

psychologically safe they might not only be less concerned with thepotential negative consequences but they might also perceive theinternal auditing as a learning mechanism by which they can obtainimportant knowledge from the auditors’ expertise as well as fromthe findings revealed by the audit. This relational process is at theheart of seeing auditing activities as helping employees unraveldeficient routines and providing them with guidance as to howovercome and solve them (Eden & Moriah, 1996). Our findingsextend previous research which indicates that fear of blameinhibits reporting medical errors and by implication impedesrather than promotes patient safety (Waring, 2005).

However, our study indicates that psychological safety is notonly important for learning, motivating to learn from the audits,and improving processes, but also can mitigate excessive buttypical apprehensions that audits are a mechanism for punishment.Rather than viewing deterrence as aiming to punish, it helpsemployees avoid repeated mistakes and remove potential trans-gressions at work (Eden & Moriah, 1996). The findings of this studyboth confirm previous research on psychological safety as a catalystfor learning behaviors (Edmondson, 1999, 2004) and extend thisline of research and thinking by showing how psychological safetycultivates perceptions of internal auditing as a quality activity forlearning, deterrence, motivation and process improvement. Facili-tating exchange and cooperation is important for improved workprocesses and outcomes (Scott et al., 2003).

The current study also contributes to the literature on organi-zational trust and perceived organizational support as initialenablers of quality internal auditing through psychological safety.Research has pointed out that both trust (Edmondson, 2004) andorganizational support (Edmondson, 1999) are important ante-cedents of psychological safety. However, our study differs fromprevious studies in two ways. First, researchers have mainly studiedinterpersonal trust as an antecedent of psychological safety, andhave not conceptualized trust in the employer as we investigatedhere. Second, studies on support–psychological safety relationshipshave mainly referred to supportive organizational context in termsof structural features such as clear compelling goal and design,whereas we tested the relationship between perceived organiza-tional support and psychological safety.

As in Robinson’s (1996) study, we examined employee trust in hisor her employer (organization). Our findings confirm Edmondson’swork that perceptions of psychological safety stem from a high levelof trust (Edmondson, 1999) and extend a line of research that indi-cates that trust in the employer is an important factor in diminishingbreaches of psychological contract (Robinson, 1996) and in buildingconditions for a reciprocal exchange agreement between theemployee and his or her organization (Rousseau, 2005).

We also shed light on the support–psychological safety rela-tionship. We show that when employees develop general beliefsthat their organization values and appreciates their contributionand cares about their well-being, they experience a higher level ofpsychological safety than employees who do not perceive theirorganization as valuing and appreciating their contribution orcaring about their well-being. This is consistent with the psycho-logical processes that underlie perceived organizational support(Eisenberger et al., 1986; Rhoades & Eisenberger, 2002).

Psychological safety was also specified in this study as a medi-ator of the relationships between both organizational trust andperceived organizational support and internal auditing. Consistentwith prior research on psychological safety, the results showedthat perceived organizational support facilitated perceptions ofpsychological safety, which in turn contributed to employees’perceptions of quality internal auditing. Psychological safety,however, partially mediated the relationship between organiza-tional trust and quality internal auditing.

From an empirical point of view, this study empiricallydemonstrates, for the first time, the relational factors underlyingquality internal auditing by identifying psychological safety as animportant intervening variable. Theoretically, it could be arguedthat organizational trust is a relatively fixed relational construct,whereas perceived organizational support might be more change-able. Thus, the effect of organizational trust on perceptions ofinternal auditing as a positive and contributing process is morecritical, especially when one considers theoretical assumptions thatauditing often produces negative feelings and leads people not tocooperate (Mints, 1972). Trust as a relatively fixed construct is alsoshown to be important in sustaining the psychological contract(Robinson, 1996; Rousseau, 2005). This suggests that through thecreation of conditions of a reciprocal exchange agreement betweenthe employees and their organization, employees may developmore positive reactions to auditing activities and see them asimportant and contributing to both the individuals and the orga-nization. Perceived organizational support, however, may be morechangeable in that people may think that the support they receivedfrom their organization during a particular event was not sufficient,but they do not lose their complete trust in the organization.Nevertheless, researchers may need to add specificity to relationalunderpinnings of psychological safety and features of auditing aslearning (Carmeli, Brueller, & Dutton, in press).

Finally, our study contributes to the literature on internalauditing in organizations by its particular emphasis on healthcaresettings. We present the first theoretical development and empir-ical test of relational underpinnings of internal auditing. This isimportant as we were able to show how and why relational factorssuch as organizational trust, perceived organizational support andpsychological safety contribute to employees’ perceptions ofquality internal auditing. Quality internal auditing, marked bylearning, deterrence, motivation and process improvement, iscritical for ensuring high reliability and helping to promote patientsafety, thus serving as an important mechanism that may havesignificant implications for both healthcare organizations and theirpatients.

Limitations

The study has a number of limitations that need to be kept inmind when interpreting its results. This study should be consideredas an initial attempt to explore the relational underpinnings ofauditing quality. In addition, beside Eden and Moriah’s (1996)study, we are not aware of other attempts to study quality internalauditing as we did here. We conducted our study in one healthcareorganization in Israel. Although we used a random sample wecannot claim generalizability until further research validates andextends our findings. Nevertheless, our model is consistent withtheory and some empirical work that has tested the relationshipsbetween trust, support and psychological safety and learning invarious work settings, including healthcare units. Although webelieve that the concept of auditing may be applicable in othersettings, similar for example to works on safety (Sexton et al.,2006), there is a need to apply multi-level modeling to understandvariability across- and within-organizations, clinics, or areas. Thus,future research is needed to shed light on internal auditing atdifferent levels of analysis.

Although we collected data at two points in time with a lag of sixmonths we cannot claim causal relationships. Nonetheless, webelieve that our theoretical reasoning behind the tested relation-ship in the model is sound. Clearly, an experimental longitudinalstudy is needed to establish such a causal relationship. In addition,as in any study, there may be unobserved variables that we have nottaken into account. For instance, we did not examine the role of

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leaders’ behaviors, nor did we test the effect of prior, importantrelational constructs such as fairness and justice. Finally, weacknowledge the potential bias associated with data that werecollected from the same source, as well as the use of the samemethod (survey) to collect our data. Results of a measurementmodel in which all items were specified to load on a single latentvariable, a test which provides in essence the one-factor test did notprovide a good fit for the data (CFI¼ .68; TLI¼ .36; RMSEA¼ .288).Although this test does not preclude potential biases its findingscombined with data collected at points in time with a lag of sixmonths may suggest that this problem is not severe in our study.

Conclusions

Internal auditing is a key managerial mechanism by whichorganizations can improve their reliability and viability. Our studysheds light on the relational underpinnings of internal auditing,suggesting that organizational trust, perceived organizationalsupport and psychological safety are important in encouragingemployees to perceive internal audits as significant and positive,rather than developing defensive and negative reactions towardthem. Integrating research on trust, support and psychologicalsafety provides the opportunity to more fully understand howrelational factors influence employees’ perceptions of internalauditing in healthcare settings.

Appendix A. Items measuring internal auditing

LearningProposals as to how to correct mistakes found in the internal audit are submitted on

a regular basis.The auditing report is an important learning tool.We lack a way to learn effectively from the auditor’s remarks (reverse-scored item).We have specific instructions and guidelines that help us learn from the mistakes

discussed in the auditing report.Auditing findings are carefully studied by all relevant members.The auditing findings are presented to all managers and members in detail so they

can learn from the mistakes and come up with solutions.

DeterrenceThe internal auditing diminishes the occurrence of disorganization.The internal auditing discourages improper procedures.The internal auditing deters members from improper behaviors.The internal auditing prompts employees to comply with the organizational rules.The internal auditing encourages all members to respect the principles of

confidentiality.The internal auditing compels members to keep patient data strictly confidential.The eventuality that the internal auditing will necessitate personal accountability

deters members from breaking the law and disregarding procedures.The internal auditing increases members’ compliance with administrative rules.

MotivationThe internal auditing motivates employees to make improvements.The internal auditing plays an important role in enhancing employee motivation to

do their work better.The auditing process generates a great deal of negative feelings in my organization

(reverse-scored item).We are motivated to learn from the internal auditing.We are interested in learning a lesson from the internal auditing.We are motivated to work together with the auditor to improve our work.We are motivated to learn from the auditing so we will be able to come up with

better work processes in the future.The internal auditing presents us with challenges we try to meet.

Process ImprovementThe internal auditing helps improve efficiency in the work process.The follow-up assessment of the internal auditing contributes to improving work

processes.The internal auditing is followed by a prospective assessment of process

improvement.The internal auditing leads to improvement in work processes.Following the internal auditing, we can point to significant changes for the better in

our work processes.

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