Abstract
This study examines the effect of ethical leadership on organizational healthcare excellence, and organizational citizenship behavior is used as an intervening variable. The study explores how ethical leadership components, such as integrity, employee orientation, and ethical direction, are associated with hospital performance excellence, addressing a gap in research on leadership in Middle Eastern healthcare organizations. Data were collected using a standardized questionnaire from 300 King Abdullah Hospital regular employees in Bisha, Saudi Arabia, using simple random sampling. Structural equation modeling aided by Stata was employed to analyze the data. The findings are that ethical leadership affects organizational citizenship behavior and organizational excellence positively with statistically significant effects. organizational citizenship behavior was a poor mediator between excellence and ethical leadership and provided evidence that, besides voluntary employee behavior, ethical leadership also has various other psychological or structural mediators. Amongst the organizational citizenship behavior dimensions, sportsmanship and civic virtue were highly correlated with their underlying construct, and the model fit indices showed that model measurement and structure were good. The strategic benefit of ethical leadership to organizational performance and climate is transferable to healthcare. In terms of managerial suggestion, findings merit the application of reward schemes and leadership development programs that reward ethical behavior and discretionary effort. Such programs are most likely to induce long-lasting excellence in healthcare organizations, particularly in reform-focused environments such as Saudi Arabia. Future research is invited to examine other situation variables and mediator factors influencing the ethical leadership–performance relationship.
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Introduction
Ethical leadership has attracted increasingly more theoretical and applied attention because it is at the center of forming employee attitudes, organizational culture, and organizational effectiveness. Ethical leadership can be typically defined as leaders demonstrating normatively appropriate behavior through their personal actions and interpersonal relationships while motivating this behavior in followers through communication, reward, and decision. This type of leadership is particularly crucial in the health sector, whose clinical decisions are directly affected by ethical leadership, which affects employees’ morale and the quality of patient care (Brown et al., 2005; Rubab et al., 2023; Goodarzi et al., 2018).
Healthcare organizations, by their very nature, require leaders who can exhibit fairness, integrity, and transparency. Ethical leadership enables trust in management, employee commitment, and a favorable and ethical organizational climate (Zhang, Liu, & Li, 2023; Zheng, Ma, Wu, & Wang, 2024) to deliver outstanding results that satisfy or exceed stakeholder expectations. In the context of the hospital, these include operational effectiveness, quality care for patients, and continuous improvement of services (Ibrahim, 2020; Alshahrani et al., 2022).
Literature captures the mediating role of employee behavior, namely, organizational citizenship behavior —on excellence-leadership associations. Organizational citizenship behavior is an enhancement of organizational effectiveness through discretionary behaviors. They involve helping others, extra effort, and commitment to organizational objectives (Montani & Desmarais, 2018; Park & Kim, 2024). Ethical leaders are more likely to enforce such behavior since they act as models of integrity and justice, create trust, and encourage employees to exceed minimum performance levels (Yozgat & Meskiran, 2016).
Though the application of such frameworks is pertinent, few empirical studies have attempted to investigate the relationship of ethical leadership with organizational citizenship behavior and organizational excellence in Middle Eastern healthcare contexts. In Saudi Arabia, where health systems are being transformed in line with Vision 2030, understanding institutional performance is especially pertinent. Nevertheless, cultural norms, hierarchical organizational structures, and differential perceptions of leadership impose challenges that are sure to influence these relationships (Alharbi et al., 2024; Alkhathami et al., 2023; Alkhathami et al., 2024).
To address this void, the current study investigates the effect of ethical leadership on organizational greatness through the mediation of organizational citizenship behavior in King Abdullah Hospital in Bisha, Saudi Arabia. The research is evidently found on Social Exchange Theory, which dictates that employees, as they perceive fairness and ethical behavior by leaders, reciprocate with positive behavior and attitudes such as organizational citizenship behavior. Social Exchange Theory provides a good theoretical basis for explaining how leadership style creates a cycle of trust, cooperation, and enhanced performance.
This study contributes three significant contributions to literature. First, it contributes theoretically to using Social Exchange Theory in explaining ethical leadership-organizational performance processes. Second, it contributes empirically through the Saudi hospital context in addressing a regional void in the literature. Third, it contributes practically through the generation of implications for healthcare managers and policymakers interested in the development of leadership practice and institutional performance to meet national reform aims. The objectives of this study include exploring the current level of employees’ perception of ethical leadership practices in King Abdullah Hospital, examining the extent to which these perceptions are associated with organizational excellence, and examining the extent to which organizational citizenship behavior mediates this relationship. Through doing so, this study contributes and therefore has theoretical, managerial, and policy implications for the Saudi Arabian healthcare context.
Theoretical framework and literature review
Ethical Leadership
Ethical leadership is usually defined as a leadership style that involves role-modeling normatively appropriate conduct through individual behavior and interpersonal interactions and inducing such behavior in others through two-way communications, positive reinforcement, and good decision-making (Brown et al., 2005). In real-world applications, ethical leaders are examples in the sense that they consistently demonstrate values of integrity, fairness, transparency, and honesty (Rubab et al., 2023). Ethical leaders are not merely ethical themselves but also model standards and norms in firms, reward others for ethical behavior, and correct misconduct when it is broken (Zheng et al., 2024).
Literature is always aware of various dimensions that constitute ethical leadership, for instance, justice (treatment of human beings in a fair and objective way), integrity (consistency of speech and actions), people-orientation (demonstrating sincere concern for the welfare of employees), role clarification (ensuring clarity in role and responsibility), and ethical guidance (always articulating ethical norms and expectations) (Zhang et al., 2023). These dimensions combined constitute an ethical and caring organizational culture where employees understand what is expected as norms and can make ethical decisions.
Organizational Impact and Importance
Ethical leadership plays an important role in many organizational outcomes. Leaders who are ethical in their daily conduct are bound to achieve the respect and trust of their employees, enhancing their commitment and motivation towards the organization (Babalola et al., 2018). This leads to improvements in psychological safety, where employees feel that their leaders care for them, hence enhancing job satisfaction and organizational commitment (Park & Kim, 2024).
As affirmed by Yozgat and Meşekıran (2016), moral leadership positively affects job satisfaction, and trust in leadership is the main mediating factor. Moral leadership is also linked with the decrease in turnover intention and organizational commitment increase, as the employees are made to feel respected and valued (Tabiu, 2023). Ethical leaders also create a working environment that deters misconduct, reduces interpersonal conflict, and promotes a culture of cooperation and justice (Babalola et al., 2018).
In addition, ethical leaders request the employees to perform more than is officially required of them. Ethical leadership has been found to generate organizational citizenship behavior, discretionary, voluntary, unrewarded actions, yet they are essential to organizational performance (Montani & Desmarais, 2018). Subordinates respond to ethical treatment and fairness by exhibiting favorable extra-role behavior. For example, Zhang et al. (2023) confirmed that ethical leadership sustains organizational citizenship behavior in ostracized workplaces via reinforcement of a positive self-concept by employees.
In governmental institutions where accountability and trustworthiness take center stage, concurrent use of ethical leadership and supportive Human Resource Management practices has been found to contribute significantly to civic-behavioral activities of the employees (Rubab et al., 2023). Drawn from Social Exchange Theory, ethical leadership is defined to facilitate high-quality exchanges between leaders and followers that establish trust, loyalty, and cooperative behavior (Podsakoff et al., 2009).
Ethical leadership is the center of organizational and ethical organizational culture formation and sustenance. Its influence is from employee attitude to behavioral outcomes and total organizational performance metrics, like innovation and operational excellence (Albdareen et al., 2024). The evidence establishes the strategic significance of ethical leadership towards attaining long-term organizational excellence.
Organizational excellence
Organizational excellence is the consistent achievement of better results and performance that exceed or match stakeholders’ expectations (Ibrahim, 2020). Excellence was, according to the American Society for Quality, defined as repeated delivery of improved results better than expectations in a way not creating inefficiencies or flaws (American Society for Quality, 2022). The European Foundation for Quality Management (Bukvič, 2023) has also given the excellence definition as a sustained attempt to build and maintain organizational systems and standards to engage and empower employees to deliver high-quality products and services that meet business goals.
Organizational excellence basically refers to gradually enhancing the processes that generate stakeholder value and confer long-term strategic goals on internal systems. Ibrahim (2020) illustrates that organizational excellence refers to achieving greater levels of performance through the utilization of employees’ creativity and innovation to satisfy stakeholders’ needs and achieve competitive differentiation.
Dimensions of organizational excellence
Several internationally acclaimed models have been developed to define and quantify organizational excellence in the long term. Some of these models are the Malcolm Baldrige National Quality Award model and the European Foundation for Quality Management Excellence Model, both of which offer methodical approaches to measuring performance and organizational improvement in performance (BukviÄŤ, 2023).
The Baldrige criteria adopt major criteria such as leadership, strategic planning, customer focus, measurement and analysis, workforce involvement, process management, and business results (American Society for Quality, 2022). The European Foundation for Quality Management model also specifies five enablers—leadership, people, strategy, partnerships & resources, and processes—and four areas of results, which include customer, people, society, and business results. The expectation here is that effective leadership and management practices (enablers) are contributing towards sustainable and measurable organizational results.
Organizations that aim for excellence adopt continuous improvement approaches based on Total Quality Management principles. These include using the Plan-Do-Check-Act cycle, internal self-assessment, and benchmarking of performance to identify gaps and drive innovation (Ibrahim, 2020; American Society for Quality, 2022). Excellence-focused organizations define measurable targets, use performance indicators, and offer chances for employees to participate in continuous improvement initiatives (Rubab et al., 2023).
Leadership is a key source of excellence. Shared vision leadership, behaviors that drive excellence, and recognition of employees’ contributions through excellent leadership create environments that enable high performance. Ethical and inclusive-value leadership approaches have been demonstrated empirically to enhance organizational excellence. For example, Park and Kim (2024) highlighted in their study that servant leadership with employees as its object of concern had a positive impact on organizational excellence, particularly in settings where the culture of this leadership type permeated.
These findings confirm that ethical and human-oriented leadership is one of the four excellence pillars. Aligning with the European Foundation for Quality Management model, it is the foundation upon which all other organizational enablers are placed (European Foundation for Quality Management, 2021). Organizational excellence also requires that leadership, culture, strategy, processes, and people be aligned to the collective purpose of delivering better results to all stakeholders.
Organizational citizenship behavior
Organizational Citizenship Behavior is a term used to describe voluntary and discretionary employee action that is not formally acknowledged by way of reward systems but is very valuable to organizational performance (Organ, 1988). Some examples of these types of behaviors include helping others, taking the initiative, and fostering a favorable organizational atmosphere. Podsakoff et al. (2009) have defined organizational citizenship behavior as a set of individual behaviors that, when performed together, positively affect the organization’s performance and function.
The five factors traditionally used in defining organizational citizenship behavior are altruism, courtesy, sportsmanship, conscientiousness, and civic virtue. Altruism involves helping other individuals; courtesy involves the effort to avoid annoying others; sportsmanship involves tolerance and good sportsmanship; conscientiousness involves going beyond the level of required work activities; and civic virtue involves being active in the governance and life of the organization (Organ, 1988).
Earlier research separates organizational citizenship behavior into two large categories: Organizational citizenship behavior towards persons, i.e., assisting or mentoring co-workers, and Organizational citizenship behavior towards the organization, e.g., facilitating company goals and protecting firm property (Borman & Motowidlo, 1997).
Antecedents of organizational citizenship behavior
There are numerous determinants of the probability of an employee displaying organizational citizenship behavior. These include the individual-level properties of conscientiousness, emotional stability, and job satisfaction, as well as perceptions of organizational justice and commitment (Podsakoff et al., 2009). Context and organizational features are also at play, such as a positive culture, open Human Resources policies, and ethical climate.
Among all the identified antecedents, leadership style is a highly important antecedent. Ethical, transformational, and servant leader styles have all been associated with higher levels of organizational citizenship behavior. Such leaders construct cultures of fairness, trust, and mutual commitment (Neubert & Roberts, 2013).
Ethical leadership, on the other hand, encourages organizational citizenship behavior through the promotion of psychological safety, displaying persistent ethicality, as well as rewarding ethicality (Tabiu, 2023). Employees of ethical leaders feel empowered, valued, and committed, and this forces them to demonstrate behaviors that go beyond their official role expectations (Rubab et al., 2023).
Consequences of organizational citizenship behavior
Organizational citizenship behavior has very significant effects on organizational performance. Among these are enhanced job performance, enhanced teamwork, reduced conflict, and overall enhanced morale (Organ et al., 1988; Das & Rajini, 2024). Moreover, organizations that have organizational citizenship behavior are also likely to have reduced turnover and absenteeism since the employees are engaged more and part of the organizational values (Podsakoff et al., 2009).
Customer-facing results also rise when organizational citizenship behavior is prevalent since workers tend to provide high-quality service and construct organizational image (Park & Kim, 2024). Within health organizations, the relevance of organizational citizenship behavior is extremely high. Proper teamwork, coordination, and effective resolution of problems have a direct effect on patient outcomes and hospital performance (Baird et al., 2017).
Enwereuzor et al. (2020) discovered that higher levels of organizational citizenship behavior among hospital nurses correlate with greater coordination, patient satisfaction, and overall effectiveness of functioning. Although organizational citizenship behavior would be beneficial, research also warns against excessive discretionary effort in that too much organizational citizenship behavior can contribute to burnout if not channeled correctly (Bolino et al., 2013). Organizations thus must balance promoting organizational citizenship behavior against support structures to ensure staff well-being.
Interplay of ethical leadership, organizational citizenship behavior, and organizational excellence
Much research shows that ethical leadership triggers organizational citizenship behavior, and this leads to organizational excellence. In the case of ethical leaders and winning the confidence of the people, employees will be more likely to go the extra mile. This action results in increased efficiency, innovation, and quality of service (Podsakoff et al., 2009). In Nigerian public sector organizations, Tabiu (2023) found that ethical leadership had a critical influence on several aspects of organizational citizenship behavior, especially when noting the integration of HR policies. Zhang et al. (2023) found that ethical leadership moderated the negative effects of workplace ostracism to induce high levels of organizational citizenship behavior. Organizational citizenship behavior produces excellence by enhancing cooperation, flexibility, and service innovation. For instance, Das and Rajini (2024) confirmed that organizational citizenship behavior positively affected employee health and work performance, while Baird et al. (2017) suggested its strong effect on patient care quality and hospital performance.
Empirical literature further recognizes the significant effect of ethical leadership in the avoidance of unethical corporate actions in the guise of earnings management. For instance, Almasarwah et al. (2025) emphasized that ethical leadership encourages openness and accountability, therefore reducing fraudulent financial reporting practices in industries globally. Their cross-national experiment with managers of 21 firms revealed a significant negative correlation between ethical leadership and earnings manipulation, further affirming the strategic benefits of ethical behavior in ensuring organizational integrity and excellence. In addition to the role of leadership in shaping discretionary behavior, Khademian (2016) demonstrated that both task- and relation-oriented leadership directly and significantly influence professional ethical conduct in business industries. Employing structural equation modeling of a cement production industry, the study validated that supportiveness and structuring of tasks into clear goals facilitate ethical action by employees. These findings further support the view that ethical leadership is both value-driven and behaviorally focused, influencing workers’ compliance with ethical concepts in different workplaces.
Moreover, empirical evidence presented by Abuzaid et al. (2024) further supports this contention by linking ethical leadership with more organizational citizenship behavior, especially in innovation-focused sectors. Through the addition of job satisfaction and leader empathy, they demonstrated that employees under the helm of ethical leadership exhibit greater levels of employee engagement and discretionary actions such as civic virtue and altruism, which play a core role in achieving sustainable organizational performance. These results validate the main hypothesis of the present study that organizational citizenship behavior is an active mediator behavior through which excellence is affected by ethical leadership.
In addition, current research has also extended the influence of ethical leadership to new horizons of performance beyond the traditional measures. Almasarwah et al. (2025) paid attention to its strategic significance in finance management, demonstrating how ethical leadership can prevent earnings management behaviors, hence guaranteeing transparency and accountability in organizations. Similarly, Li (2024) directed attention to the moderating role of leader empathy in stimulating the linkage among ethical leadership, internal job satisfaction, and organizational citizenship behavior in emerging industries. These works underscore the shifting place of ethical leadership as a deep construct that supports interpersonal employee outcomes and macro-governance objectives. They also provide evidence for the argument that empathy and emotional intelligence are central to advancing the positive effects of ethical leadership.
Mediating role of organizational citizenship behavior
Empirical evidence supports organizational citizenship behavior as a mediator of the relationship between ethical leadership and organizational excellence. Ishak and Williams (2020) found partial mediation for the stated relationship, signifying organizational citizenship behavior is a significant but not sole mechanism through which ethical leadership impacts performance. Zehir et al. (2011) demonstrated full mediation, highlighting the influence of employee behavior in bringing the values of leadership to performance outcomes. Khokhar and Zia-ur-Rehman (2017) also supported the concept of two paths—direct and indirect—between ethical leadership and excellence.
Conceptual model and hypotheses
Drawing on social exchange theory, this study offers a conceptual framework under which ethical leadership has a positive direct and indirect effect on organizational excellence via organizational citizenship behavior.
Research Hypotheses
H1: Organizational citizenship behavior mediates the relationship between ethical leadership and organizational excellence, such that ethical leadership increases organizational citizenship behavior, which in turn enhances organizational excellence.
H1.1: Ethical leadership has a positive direct effect on organizational excellence.
H1.2: Ethical leadership has a positive effect on employees’ organizational citizenship behavior.
This study focuses on employees at King Abdullah Hospital in Bisha, Saudi Arabia, providing a context-specific examination of these relationships in the healthcare sector. By testing these hypotheses, the study aims to advance theoretical understanding and provide practical insights for healthcare leaders seeking to enhance organizational excellence through ethical leadership.
Methodology
Research design and approach
The study employed a quantitative research design to explore the interrelationships between ethical leadership, organizational citizenship behavior, and organizational excellence within a health care setting. While an earlier draft of the study considered employing a mixed-methods design, the final deployment was exclusively on quantitative data. This allowed statistical testing of hypothesized relationships using standardized measures and high-strength analytical techniques (Creswell & Plano Clark, 2018).
The cross-sectional survey method was preferred because through it, researchers are in a position to get data from a large sample at a single moment in time and establish correlations and mediation effects between variables. The method is suitable for studies whose objective is to test theoretical models in organizational behavior and leadership contexts.
Sampling and participants
The population under study was full-time employees at King Abdullah Hospital in Bisha, Saudi Arabia, including administrative and clinical staff. A simple random sampling technique was used based on HR records as the sample frame to give an equal opportunity of being selected to each of the individuals (Bryman, 2016).
The sample size was calculated through the formula advanced by Krejcie and Morgan (1970) for known population sizes. With the total number of hospital staff being 1118, the sample size needed was about 285. To compensate for potential non-response, in the initial survey, questionnaires were issued to 350 workers. A total of 300 valid responses were ultimately received, representing a response rate of 85%.
The sample was a representative cross-section of departments and demographic variables. Gender, age, job title, and job tenure data were collected to produce a profile of the sample and allow subgroup analysis. Diversity improved the generalizability of the results to healthcare roles.
Data Collection Procedure
Data was collected using a self-completed, structured questionnaire provided both on paper and electronic media. The duration of the data collection lasted for a four-month period. Prior to survey release, the study acquired institutional ethical clearance according to the World Medical Association (2013) guidelines.
Online questionnaires were administered via Google Forms, and paper questionnaires were administered by Human Resource personnel to cater to employees who lacked access to computers. Invitations were followed by a letter of purpose describing the research, confidentiality guarantees, and a notification on volunteerism (Bell et al., 2022). Respondents had two weeks to fill out the questionnaires, with reminders sent midway through the data collection period to ensure high response rates.
Although 20 of the participants provided longer answers to open-ended questions, these were only utilized for contextual understanding and not for data analysis. The study was treated as completely quantitative, and no interviews or formal qualitative methods were utilized.
The three main variables (ethics leadership—independent, organizational citizenship behavior—dictating variable, and organizational excellence—dependent) were assessed through validated scales. All items were rated on a five-point Likert scale from 1 (strongly disagree) to 5 (strongly agree) (Likert, 1932). The questionnaire was translated into Arabic and back-translated to English to examine semantic and cultural equivalence (Brislin, 1970).
Ethical leadership was assessed on the Ethical Leadership at Work scale of Kalshoven et al. (2011). This 30-item scale consists of five dimensions: fairness, integrity, people orientation, role clarification, and ethical guidance. Internal consistency was strong (Cronbach’s α = 0.97).
Organizational Citizenship Behavior was measured using Podsakoff et al., (1990) 25-item scale comprising altruism, courtesy, sportsmanship, conscientiousness, and civic virtue. Reliability was determined using Cronbach’s alpha of 0.976.
Organizational Excellence was assessed using a 30-item scale questionnaire grounded on the European Foundation for Quality Management Excellence Model (BukviÄŤ, 2023). The questionnaire tested five domains: leadership and strategy, organizational culture, stakeholders, sustainable value creation, and performance and transformation. Its reliability coefficient was 0.962, which is standard in European Foundation for Quality Management -related studies.
Data analysis
Data was analyzed using Stata (Version 22). The following statistical methods were applied in hypothesis testing and model validity: Descriptive statistics were employed to describe item-level and demographic responses. Reliability testing was conducted through Cronbach’s alpha and split-half procedures for determining the internal consistency of scales. Construct validity was assessed by fit indices such as Goodness of Fit Index, Adjusted Goodness of Fit Index, Comparative Fit Index, Tucker-Lewis Index, Root Mean Square Error of Approximation, and Root Mean Square Residual using Confirmatory Factor Analysis. Pearson Correlation performed correlations among ethical leadership, Organizational Citizenship Behavior, and organizational excellence. Structural Equation Modeling performed hypothesized direct and indirect effects among constructs. Path analysis provided standardized regression weights and explained variances. One-way ANOVA disclosed statistically significant differences among demographic subgroups. The Kolmogorov-Smirnov (K-S) test tested the normality of variable distributions. Mediation analysis, accompanied by bootstrapping (5000 samples), was conducted to test the mediating effect of organizational citizenship behavior and estimate confidence intervals. The application of this method improved methodological rigor and enabled empirical testing of the theoretical model of the study.
Ethical considerations
The study followed procedures as presented by the American Psychological Association (2020) and the Declaration of Helsinki. These precautions included: Informed consent was obtained, with participants being made aware of their rights, why the study was being undertaken, and that it was voluntary. Confidentiality was maintained, with answers anonymous and safe, so there were no identifiers (Bell et al., 2022). Data security was maintained, with electronic data held and protected using password-encrypted media and paper responses in locked files (Saunders et al., 2019). In risk reduction, the use of neutral words in questionnaire items and pilot testing causes minimal emotional or psychological risk (Bryman, 2016).
Lastly, the design employed in the research gave a strict and ethical grounding for assessing the impact of ethical leadership on organizational citizenship behavior and organizational excellence in the healthcare environment. Use of strict design and tested tools ensured the validity and generalizability of findings from the study.
Methodology
Research design and approach
The study employed a quantitative research design to explore the interrelationships between ethical leadership, organizational citizenship behavior, and organizational excellence within a health care setting. While an earlier draft of the study considered employing a mixed-methods design, the final deployment was exclusively on quantitative data. This allowed statistical testing of hypothesized relationships using standardized measures and high-strength analytical techniques (Creswell & Plano Clark, 2018).
The cross-sectional survey method was preferred because through it, researchers are in a position to get data from a large sample at a single moment in time and establish correlations and mediation effects between variables. The method is suitable for studies whose objective is to test theoretical models in organizational behavior and leadership contexts.
Sampling and participants
The population under study was full-time employees at King Abdullah Hospital in Bisha, Saudi Arabia, including administrative and clinical staff. A simple random sampling technique was used based on HR records as the sample frame to give an equal opportunity of being selected to each of the individuals (Bryman, 2016).
The sample size was calculated through the formula advanced by Krejcie and Morgan (1970) for known population sizes. With the total number of hospital staff being 1,118, the sample size needed was about 285. To compensate for potential non-response, in the initial survey, questionnaires were issued to 350 workers. A total of 300 valid responses were ultimately received, representing a response rate of 85%.
The sample was a representative cross-section of departments and demographic variables. Gender, age, job title, and job tenure data were collected to produce a profile of the sample and allow subgroup analysis. Diversity improved the generalizability of the results to healthcare roles.
Data collection procedure
Data was collected using a self-completed, structured questionnaire provided both on paper and electronic media. The duration of the data collection lasted for a four-month period. Prior to survey release, the study acquired institutional ethical clearance according to the World Medical Association (2013) guidelines.
Online questionnaires were administered via Google Forms and paper questionnaires by HR personnel to cater to employees who lacked access to computers. Invitations were followed by a letter of purpose describing the research, confidentiality guarantees, and a notification on volunteerism (Bell et al., 2022). Respondents had two weeks to fill out the questionnaires, with reminders sent midway through the data collection period to ensure high response rates.
Although 20 of the participants provided longer answers to open-ended questions, these were only utilized for contextual understanding and not for data analysis. The study was treated as completely quantitative, and no interviews or formal qualitative methods were utilized.
The three main variables (ethics leadership—independent, organizational citizenship behavior—dictating variable, and organizational excellence—dependent) were assessed through validated scales. All items were rated on a five-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). The questionnaire was translated into Arabic and back-translated to English to examine semantic and cultural equivalence (Brislin, 1970).
Ethical leadership was assessed on the Ethical Leadership at Work scale of Kalshoven et al. (2011). This 30-item scale consists of five dimensions: fairness, integrity, people orientation, role clarification, and ethical guidance. Internal consistency was strong (Cronbach’s α = 0.97).
Organizational Citizenship Behavior was measured using Podsakoff et al.’s (1990) 25-item scale comprising altruism, courtesy, sportsmanship, conscientiousness, and civic virtue. Reliability was determined using Cronbach’s alpha of 0.976.
Organizational Excellence was assessed using a 30-item scale questionnaire grounded on the European Foundation for Quality Management Excellence Model (BukviÄŤ, 2023). The questionnaire tested five domains: leadership and strategy, organizational culture, stakeholders, sustainable value creation, and performance and transformation. Its reliability coefficient was 0.962, which is standard in European Foundation for Quality Management -related studies.
Data analysis
Data was analyzed using Stata (Version 22). The following statistical methods were applied in hypothesis testing and model validity: Descriptive statistics were employed to describe item-level and demographic responses. Reliability testing was conducted through Cronbach’s alpha and split-half procedures for determining the internal consistency of scales. Construct validity was assessed by fit indices such as Goodness of Fit Index, Adjusted Goodness of Fit Index, Comparative Fit Index, Tucker-Lewis Index, Root Mean Square Error of Approximation, and Root Mean Square Residual using Confirmatory Factor Analysis. Pearson Correlation performed correlations among ethical leadership, Organizational Citizenship Behavior, and organizational excellence. Structural Equation Modeling performed hypothesized direct and indirect effects among constructs. Path analysis provided standardized regression weights and explained variances. One-way ANOVA disclosed statistically significant differences among demographic subgroups. The Kolmogorov-Smirnov (K-S) test tested the normality of variable distributions. Mediation analysis, accompanied by bootstrapping (5000 samples), was conducted to test the mediating effect of organizational citizenship behavior and estimate confidence intervals. The application of this method improved methodological rigor and enabled empirical testing of the theoretical model of the study.
Ethical considerations
The study followed procedures as presented by the American Psychological Association (2020) and the Declaration of Helsinki. These precautions included: Informed consent was obtained, with participants being made aware of their rights, why the study was being undertaken, and that it was voluntary. Confidentiality was maintained, with answers anonymous and safe, so there were no identifiers (Bell et al., 2022). Data security was maintained, with electronic data held and protected using password-encrypted media and paper responses in locked files (Saunders et al., 2019). In risk reduction, the use of neutral words in questionnaire items and pilot testing causes minimal emotional or psychological risk (Bryman, 2016).
Lastly, the design employed in the research gave a strict and ethical grounding for assessing the impact of ethical leadership on organizational citizenship behavior and organizational excellence in the healthcare environment. Use of strict design and tested tools ensured the validity and generalizability of findings from the study.
Results
Measurement validity and reliability analysis
To determine if the measurement instruments utilized in this research were valid and reliable, a pilot test of 40 randomly selected respondents was carried out. The three principal constructs—ethical leadership (independent variable), organizational citizenship behavior (mediator), and organizational excellence (dependent variable)—were tested via Cronbach’s alpha and split-half reliability.
The Ethical Leadership scale, with 30 items across five subdimensions, was highly consistent internally. Table 1 shows that all the subscales had Cronbach’s alpha between 0.893 (integrity) and 0.920 (role clarification) and that the overall value was 0.973. Split-half reliability stood at 0.918, which is a testament to the stability of the scale. The role clarification subdimension scored the most consistency, which indicated unambiguous understanding among participants.
Reliability and Validity of Ethical Leadership
The independent variable, ethical leadership is hypothesized to influence organizational citizenship behavior and organizational excellence. It was measured using five key dimensions with 30 items.
As shown in Table 1, Cronbach’s alpha ranged from 0.889 (Employee Orientation) to 0.920 (Role Clarification), and for overall reliability, it was 0.973. Split-half values also established this consistency reaching 0.918.
Reliability and validity of organizational excellence
The dependent variable, organizational excellence, was measured using five dimensions with 30 items.
As shown in Table 2, Cronbach’s alpha ranged from 0.802 (performance & change management) to 0.895 (organizational culture), and for overall reliability, it was 0.962. Split-half values also established this consistency, with vision, strategy, & goals reaching 0.902.
Reliability and validity of organizational citizenship behavior
The mediating variable, organizational citizenship behavior, consists of five key dimensions with 25 items.
As shown in Table 3. Cronbach’s alpha values range from 0.878 to 0.893, confirming high internal reliability. Overall, Cronbach’s alpha of 0.976 indicates excellent reliability. Split-half reliability values confirm strong consistency, particularly for conscientiousness (0.932).
Summary of Reliability and Validity Metrics
As we see in Table 4. These values exceed the tolerated reliability values and validate the internal consistency and validity of the constructs measured. Based on these findings, the instruments used in the research are deemed adequate for higher-level analyses such as confirmatory factor analysis and structural equation modeling.
Confirmatory factor analysis
To affirm the structure of the measurement models used in this study, a confirmatory factor analysis was performed. The technique was used to test whether the observed variables measured their respective underlying latent variables. Several fit indices were used to ascertain the fitness of the models, including Chi-square to degrees of freedom ratio, Goodness of Fit Index, Adjusted Goodness of Fit Index, Normed Fit Index, Comparative Fit Index, Tucker-Lewis Index, Incremental Fit Index, Root Mean Square Residual, and Root Mean Square Error of Approximation. A well-fitting model is indicated as Chi-square to degrees of freedom ratio is less than 5, the Goodness of Fit Index, Comparative Fit Index, Incremental Fit Index, Normed Fit Index, and Tucker-Lewis Index are greater than or equal to 0.90, and the Root Mean Square Error of Approximation is less than or equal to 0.08.
Ethical leadership model
As presented in Table 5, The Confirmatory Factor Analysis results for ethical leadership showed strong factor loadings for all five dimensions. Integrity (1.222) and employee orientation (1.186) reported the highest standardized loadings, which show their dominant influence on the latent construct. Although ethical guidance showed the lowest load (0.554), it was statistically significant (p < 0.001). This factor structure is visually illustrated in Fig. 1, which depicts the path diagram for ethical leadership.
Path Diagram for Ethical Leadership.
As Table 6. Shows All measures of model fit were tested to a fantastic fit of data and structure hypothesized. The Chi-square to degrees of freedom ratio of the model was far less than 5.0, indicating a good fit. Additionally, all comparative and incremental fit measures, including the Comparative Fit Index, Incremental Fit Index, Normed Fit Index, and Tucker-Lewis Index—were greater than 0.90. The Root Mean Square Error of Approximation was very low (0.033), further testifying to the strength and sufficiency of the model. Confirmatory Factor Analysis (CFA) estimates for organizational excellence also validated the factor structure. Vision & Strategy was the reference item with a fixed loading, while stakeholder engagement (1.421), sustainable value (1.674), and performance & change (1.595) were the strongest indicating factors.
Organizational excellence model
It can be observed from Table 7 that the five organizational excellence dimensions also loaded highly on the latent construct. Sustainable Value (1.674), Performance & Change Management (1.595), and Stakeholder Engagement (1.421) also had extremely strong standardized loadings.
Figure 2 presents the measurement model for this construction. The model fit indices shown in Table 8 further confirm its adequacy, including a Goodness of Fit Index of 0.949 and a Root Mean Square Error of Approximation of 0.029, both indicating an excellent fit to the data.
Path Diagram for Organizational Excellence.
Organizational citizenship behavior model
Confirmatory Factor Analysis results for organizational citizenship behavior are presented in Table 9, and all five dimensions—Altruism, Courtesy, Conscientiousness, Civic Virtue, and Sportsmanship—have statistically significant factor loadings (p < 0.001). Courtesy (1.036) and Conscientiousness (1.035) made the highest contributions. Structural relations are depicted in Fig. 3.
Path Diagram for Organizational Citizenship Behavior.
Converging model fit indices in Table 10 support that the organizational citizenship behavior measurement model fits well with RMSEA = 0.030 and all the other fit indices >0.90.
Overall, Confirmatory Factor Analysis results provided strong support for the construct validity of the three latent variables under investigation. All constructions had statistically significant and theoretically congruent factor loadings. Moreover, all the model fit statistics suggested that the measurement models were well specified and fit the data well, and the results thus provided a good foundation for future structural modeling and hypothesis testing.
Construct validity (Structural Validity)
To determine construct validity, the study examined the correlation of every subdimension with the respective higher-order construct. Table 11 presents Pearson correlation coefficients together with significant values.
The table above confirms that all subdimensions are significantly related to their parent constructions (p < 0.05), The value of 0.953 represents the strength of the statistical relationship, which is very high and positive. The associated significance value (p = 0.000) indicates that this relationship is statistically significant at the 0.001 level thereby supporting convergent validity. The highest correlations were for sportsmanship (0.992) and civic virtue (0.978), reflecting their core positions in the measurement of organizational citizenship behavior.
Normality Test
K-S testing was employed to determine whether distributions of data closely resemble normality. Table 12 provides a summary of the Z-scores and p-values for each of the constructs and subdimensions.
All constructions’ p values were above 0.05; therefore, not rejecting the null hypothesis of normal distribution. This indicates that data is susceptible to parametric testing, including regression.
Results from construct validity analysis confirmed strong and statistically significant interrelations among latent constructs and their subdimensions. Results from normality tests showed data was normally distributed, fulfilling major assumptions required for parametric analyses.
Testing Study Hypotheses
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Testing H1.1: Ethical leadership has a positive direct effect on organizational excellence.
To test the proposed hypotheses, structural equation modeling was employed to evaluate both direct and indirect relationships among ethical leadership, organizational citizenship behavior, and organizational excellence. The primary hypothesis posited that ethical leadership has a positive direct effect on organizational excellence. This hypothesis was further divided into five sub-hypotheses, each corresponding to a subdimension of ethical leadership.
The results of Structural equation modeling analysis, presented in Table 13, show that integrity, employee orientation, and ethical guidance exert statistically significant positive effects on organizational excellence. Integrity had the strongest standardized effect (β = 0.501, p < 0.001), followed by employee orientation (β = 0.427, p < 0.001) and ethical guidance (β = 0.090, p < 0.001). Justice and role clarification, however, did not exhibit statistically significant effects, with p-values exceeding the 0.05 threshold. The overall standardized estimate for ethical leadership’s influence on organizational excellence was 0.918, indicating a robust positive relationship, The path diagram depicting this model is given in Fig. 4. Model fit indices (Table 14) once again establish good fit (e.g., Root Mean Square Error of Approximation = 0.028, Comparative Fit Index = 0.955).
Structural Equation Model for the First Hypothesis.
The model fit indices provided in Table 14 indicate an excellent fit between the model and the data. All key indicators exceed the recommended thresholds, The model demonstrated good fit, including a normed chi-square value of 3.515 (less than the acceptable threshold of 5.0), a Goodness of Fit Index of 0.975, a Normed Fit Index of 0.983, an Incremental Fit Index of 0.978, a Tucker-Lewis Index of 0.967, a Comparative Fit Index of 0.955, and a Root Mean Square Error of Approximation of 0.028.
- Testing H1.2: Ethical leadership has a positive effect on employees’ organizational citizenship behavior.
The second hypothesis examined the relationship between ethical leadership and organizational citizenship behavior. This relationship was also decomposed into five sub-hypotheses. Table 15 and Fig. 5. indicates that all dimensions of ethical leadership—justice, integrity, employee orientation, role clarification, and ethical guidance—exerted statistically significant positive effects on organizational citizenship behavior. The highest effect was observed for integrity (β = 0.986), followed closely by justice (β = 0.974), with all p-values less than 0.001.
Structural Equation Model for the Second Hypothesis.
This hypothesis was divided into five sub-hypotheses, and Structural equation modeling was used to assess the relationship between the independent variable (ethical leadership) and the mediating variable (organizational citizenship behavior).
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Testing H1 (The main hypothesis): “Organizational citizenship behavior mediates the relationship between ethical leadership and organizational excellence, such that ethical leadership increases organizational citizenship behavior, which in turn enhances organizational excellence.” Path analysis was conducted using Stata 21 to assess direct and indirect effects.
The final hypothesis proposed that organizational citizenship behavior mediates the relationship between ethical leadership and organizational excellence. Correlation coefficients among the three key constructs are shown in Table 16 and were all significant (p < 0.01). The mediating effect was also investigated using path analysis in Fig. 6, and findings are given in Table 17. The analysis confirmed partial mediation with an indirect effect of 0.021 as well as significant direct effects. Ethical leadership correlates strongly with both organizational citizenship behavior (r = 0.882) and organizational excellence (r = 0.939), while organizational citizenship behavior also correlates with organizational excellence (r = 0.888), all at p < 0.01.
Structural Equation Model for the main hypothesis.
The analysis indicated that ethical leadership has a direct effect on organizational excellence (0.689) and a direct effect on organizational citizenship behavior (0.293). Additionally, the indirect effect of ethical leadership on organizational excellence through organizational citizenship behavior was 0.021, suggesting partial mediation.
Discussion
This study offers empirical support for the interaction among ethical leadership, organizational citizenship behavior, and organizational excellence in a Saudi Arabian healthcare context. The findings supplement and enrich existing literature by establishing that ethical leadership not only reinforces discretionary employee behavior but also has a significant effect on organizational performance outcomes. Moreover, the partial mediating role of organizational citizenship behavior is an indication that while employees’ voluntary behaviors are central to the process, they are not the sole vehicle of ethical leadership influencing excellence.
Ethical leadership and organizational excellence
The evidence attests to previous research showing that ethical leadership is a driver for higher organizational performance. This concurs with Brown et al. (2005) and Kalshoven et al. (2011), who mentioned ethical leadership as a strategic source of employee behavior and organizational climate. The strong integrity and employee-centered impacts identified in this study fortify the contention that ethical leaders create shared vision, justice, and high expectations that collectively form a culture of excellence (Albdareen et al., 2024; Babalola et al., 2018).
Ethical leadership and organizational citizenship behavior
This study further supports a robust relationship between ethical leadership and organizational citizenship behavior, paralleling findings offered by Podsakoff et al. (2009) and Neubert and Roberts (2013), who illustrated that ethical behavior at the top encourages employees to go beyond their formal roles. The results are also aligned with Social Exchange Theory, which proposes managers’ fair and moral treatment generates trust and duty, which leads employees to reciprocate with behaviors that benefit the organization (Rubab et al., 2023). In particular, the stress on justice and integrity aligns with prior studies by Khokhar and Rehman (2017), which found these dimensions to be crucial in organizational loyalty development and the prevention of deviance.
The mediating role of organizational citizenship behavior
Despite organizational citizenship behavior’s significant function in organizational excellence, a partial mediating effect was noted. This nuance is consistent with studies such as Ishak and Williams (2020), which determined that organizational citizenship behavior was infiltrating the relationship between leadership and performance but not fully explaining the variance. Our results show that there is an impact of ethical leadership through many psychological and structural mechanisms. For instance, measures like job satisfaction (Baird et al., 2017), empowerment (Montani & Desmarais, 2018), and commitment (Borman & Motowidlo, 1997) can serve as alternative or parallel mediators. The partial mediation further suggests that future research must include moderators like organizational culture or leadership empathy to better explain contextual strength of ethical leadership outcomes, particularly in non-Western health care contexts.
Conclusion
The present research provides rigorous empirical support for the assumption that ethical leadership is a basis of individual-level conduct as well as organization-level performance. Ethical leaders build trust and a justice and accountability culture that, in turn, boosts organizational citizenship behavior and organizational excellence. Although organizational citizenship behavior is contributory, the findings show that its mediating role is non-exclusive, thus allowing further research to explore other explanatory variables. This shows the wide-reaching effect of leadership ethics on organizational outcomes.
Implications
Theoretical implications
The study enriches existing literature by empirically validating the multidimensional relationship between ethical leadership, Organizational citizenship behavior, and organizational excellence. The study advances leadership theory in suggesting that ethical leadership is not the only mechanism accounting for all paths to excellence and that organizational citizenship behavior is only partially a mediator. The findings call for extensions of theories with complementary mediators and contextual factors.
Practical implications
From the management perspective, the findings highlight the need to integrate ethical leadership development in organizational strategy. Companies, particularly in healthcare, must implement formal ethics-based leadership training to instill norms such as fairness, transparency, and accountability. Human resource practices should shore up ethical behavior and encourage behaviors that enhance group performance. Supporting organizational citizenship behavior via reward systems and participative leadership practices can further enhance organizational order and productivity.
Limitations and future research directions
Despite its contribution, the research is limited. Its cross-sectional design precludes causal inference, and future studies are best conducted by employing longitudinal designs to track temporal change in the influence of leadership. The study setting—limited to a Saudi public hospital—will also limit the external validity of the results. Cross-industry and cross-cultural extensions would provide broader generalizability. Furthermore, the partial mediating effect of organizational citizenship behavior implies that other possible mediators, such as psychological empowerment, affective commitment, and employee well-being should be examined to derive additional insight into mechanisms through which ethical leadership generates excellence.
In brief, this study verifies the strategic worth of ethical leadership in developing high-performance, value-based organizations. Through embedding ethics into practice and organizational culture, organizations can sustain excellence and achieve sustained competitive success within a challenging and rapidly changing environment.
Data availability
The dataset used for this study is available in the attached supplementary file.
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Acknowledgements
The authors are thankful to the Deanship of Graduate Studies and Scientific Research at University of Bisha for supporting this work through the Fast-Track Research Support Program.
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Conceptualization: Fahad Saeed Almanbahi, Abdelrehim Awad, Adel Ghonim, Nabil Mohammed Alabsy, Mohamed Shemais. Data curation: Fahad Saeed Almanbahi, Abdelrehim Awad. Formal analysis: Abdelrehim Awad. Methodology: Abdelrehim Awad. Supervision: Abdelrehim Awad. Writing – original draft: Fahad Saeed Almanbahi, Abdelrehim Awad, Adel Ghonim, Nabil Mohammed Alabsy, Mohamed Shemais. Writing – review & editing: Fahad Saeed Almanbahi, Abdelrehim Awad, Adel Ghonim, Nabil Mohammed Alabsy, Mohamed Shemais.
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Ethical Approval
All the experimental procedures performed in research on human participants were conducted according to the ethical principles of the respective institutional ethics committees and of the 1964 Declaration of Helsinki and its later amendments or analogous ethical standards. Approval from the General Supervisor of Scientific Research, King Abdullah Hospital, Bisha, Saudi Arabia, Ethics and Scientific Research Committee was received on 15 October 2024, with approval number 20102024.
Informed Consent
Informed consent was given by all individual respondents who were included in the study. All the respondents were informed of the purpose of the research, their voluntary participation, and their right to confidentiality prior to their participation. This was explicitly stated at the beginning of the questionnaire, and continuation of the survey was considered as giving informed consent. Informed consent was obtained on 16 October 2024, prior to the distribution of the questionnaires, in both written and digital form.
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Saeed Almanbahi, F., Awad, A., Ghonim, A. et al. Ethical leadership and organizational excellence: the mediating role of citizenship behavior in healthcare. Humanit Soc Sci Commun 12, 1392 (2025). https://doi.org/10.1057/s41599-025-05743-6
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DOI: https://doi.org/10.1057/s41599-025-05743-6
