Organ donation functions as a means of sustaining and continuing life and provides practical contributions to human society. According to statistics from the China Human Organ Donation Management Center (2025), as of July 2025, over 60,200 organ donation cases had been recorded, with more than 187,000 organs donated, saving in excess of 100,000 patients suffering from organ failure. Given the critical role of organ donation in advancing human health and societal welfare, an increasing body of research has examined the antecedent mechanisms and boundary conditions influencing coordinators’ advice-giving behaviors in the context of organ donation (Anthony et al., 2021; Jiménez Oliver, 2023; Lenzi et al., 2014; Sandiumenge et al., 2020; Vincent et al., 2019).

 

Nevertheless, we have identified limitations to the current literature on advice giving for organ donation. First, studies have neglected to examine the impact of factors such as organizational relationships on the advisor’s social cognition. The organ donor coordinator is a member of the hospital or organ procurement organization who also proposes organ donation to family members outside these institutions. The leader–employee relationship in the hospital or organ procurement organization provides a new research perspective for behavioral decision making (Wang et al., 2009). Second, the organizational environment, as a key social-context factor, also affects employees’ advice-giving behavior (Duan & Zhang, 2012). For example, organizational support is likely to have a significant impact on employees’ advice behavior. Therefore, the impact of organizations on individuals needs further clarification. Third, in the process of advice giving, employees’ personal characteristics may affect their behavioral intentions (Haran et al., 2022; Hertz et al., 2020; Zaatri et al., 2022), which requires further study.

 

We used social exchange theory (Blau, 1964) to explore the influence of transformational leadership on coordinators’ advice giving. This theory holds that exchange between individuals in a society occurs all the time, with both parties having valuable social and economic resources that the other party wants, and the realization of the exchange depends on the trust relationship between the two parties (Cropanzano & Mitchell, 2005). According to Ahmad et al. (2023), social exchange theory is one of the most influential theories in the social sciences, which has implications across various fields including organizational citizenship behavior (Organ, 1990), supervisory and organizational support (Ladd & Henry, 2000), and justice (Tepper & Taylor, 2003). On the basis of social exchange theory, transformational leaders may allow coordinators to feel the respect and trust of their superiors through communication, consultation, support, and encouragement. Due to the reciprocal effect of social exchange, the coordinator’s own sense of organizational belonging may be enhanced, and they may carry out advice giving for organ donation with a positive attitude. Therefore, we anticipated that transformational leadership may motivate coordinators to offer advice to the families of organ donors, alleviate concerns experienced by coordinators after giving advice, and create a stable organizational environment for advice giving.

Burns (1978) first proposed transformational leadership as a process where leaders and followers raise one another to higher levels of morality and motivation. Transformational leaders inspire and empower subordinates to transcend their self-interest for the sake of the organization by providing a compelling vision, intellectual stimulation, and individualized consideration (Bass, 1995). From the perspective of organizational relationships, leaders and their subordinate coordinators are stakeholders in the hospital organization, and they may cultivate and establish a relationship of mutual trust and naturally form a series of exchanges. Transformational leaders may be different from other types of leaders as they may focus on cultivating high-quality relationships with team members. Transformational leaders have less concept of power distance and have closer relationships with subordinates (Bass, 1995).

 

Advice giving is a way to exert interpersonal influence on others to gain professional prestige, which is a new and undeveloped research direction in the field of decision making (Schaerer et al., 2018). Giving advice usually refers to providing solutions to other people’s difficult decision-making situations (Goldsmith & Fitch, 1997). Studies have provided empirical evidence showing advice influences the decisions and behavior of the person being advised (Gino et al., 2012; Soll & Larrick, 2009). Most scholars have investigated advice taking, suggesting that multiple factors affect decision makers’ likelihood of accepting advice, such as the characteristics of the advice (Tzioti et al., 2014), tasks (Rader et al., 2015), and advisors (Reyt et al., 2016). In addition, previous studies have focused on employees within the organization displaying voice behavior to their superiors (often viewed as an internal form of advice giving), largely ignoring the organizational behavior mechanism of employees to giving advice to external persons (Morrison, 2011, 2014).

 

Leadership style and behavior significantly influence the advice-giving tendencies of employees (Detert & Burris, 2007). In particular, transformational leaders reshape how employees perceive their professional boundaries and social influence, as employees are inclined to engage in a particular behavior when they view it as part of their in-role responsibilities; such engagement provides advisors with a sense of influence over others’ actions, which, in turn, enhances their perceived sense of power (Schaerer et al., 2018). Transformational leaders may facilitate this process by emphasizing the prosocial mission of organ donation, thereby expanding the coordinator’s perception of their in-role responsibilities to include proactive advice giving.

 

For both advisors and advice seekers, the professional knowledge of the former plays a positive role in the proposal process (Guntzviller et al., 2020). In the hospital organization, healthcare professionals possess high levels of clinical ability, ethical accomplishment, and communication skills (Links et al., 2019; Olive & Abercrombie, 2017). Transformational leadership may motivate these healthcare professionals, including coordinators, nurses, physicians, and organ procurement center staff, to apply their expertise more effectively. This supportive leadership is essential when healthcare professionals approach families to discuss consent to organ donation, as it provides the necessary organizational backing for such complex interactions (Pengel et al., 2025). Thus, we proposed the following hypothesis:

Hypothesis 1: Transformational leadership will be positively related to the advice-giving behavior of organ donation coordinators.

 

An individual’s perception of risk and sense of responsibility can affect their advice-giving behavior. On one hand, perceived risk describes how individuals assess the probability and potential damage of a threat (Babcicky & Seebauer, 2017). Advice-giving behavior is subject to the risk of rejection, and when individuals perceive that their advice has little chance of being adopted by others, they are less willing to offer it (Bonaccio & Dalal, 2006). Organ donation is characterized by complex moral, ethical, family, and other factors that may lead to a greater risk in giving advice compared with other types of advice-giving behavior, thus reducing the willingness of the coordinator to give advice. In some cases, family members may reject organ donation and opt not to seek help from the coordinator on their own initiative; therefore, if the coordinator gives subsequent advice, it is considered intrusive and faces a high risk of rejection (Deelstra et al., 2003). When the leader of the coordinator adopts a transformational leadership style, this may help to reduce the coordinator’s perceived risk by creating a positive working atmosphere, emphasizing emotional resonance and trust, and supporting the development of employees, so that the coordinator may be willing to give advice to the family members about organ donation under the care of such leadership. In short, transformational leadership may help to reduce the perceived risk of the coordinator and increase the probability of giving advice.

 

On the other hand, concern and encouragement from the transformational leader may simultaneously enhance the perceived obligation felt by the coordinator. Perceived obligation refers to an employee’s commitment and sense of responsibility to fulfill their role in the organization, which is usually manifested in the employee’s willingness to make extra efforts and sacrifice for the benefit of the organization (Eisenberger et al., 2001). When employees believe that their superiors or organizations are very concerned about and recognize their work, they will help the organization achieve its goals, so they will work more actively and promote the long-term development of the organization (Eisenberger et al., 1987). In other words, the formation of employees’ perceived obligation largely comes from the motivation of leaders. In practice, transformational leadership can help employees feel their importance in the organization and be more willing to work hard to achieve common goals by stimulating their passion and sense of responsibility, providing personalized support and guidance, and tolerating failure (Bass, 1999). Studies have found that when individuals give advice, they often hope that their advice can help others’ behavior (Cialdini & Goldstein, 2004). Therefore, we anticipated that when the coordinator’s perceived obligation is enhanced—whether from the perspective of the economic consequences of putting forward advice for organ donation, which can increase the number of organ donors, thereby improving their own and organizational performance, or from the perspective of social value—giving appropriate donation advice will help alleviate the psychological burden of donor families and save the lives of organ failure patients. The willingness to give donation advice, as a positive externality behavior, may then also increase. Thus, we proposed the following hypothesis:

Hypothesis 2: Perceived risk and perceived obligation will mediate the relationship between transformational leadership and the advice‐giving behavior of organ donation coordinators.

In examining the relationships between perceived risk, perceived obligation, and advice giving for organ donation, we incorporated perceived organizational support—a key subjective cognitive variable among employees—to investigate its moderating effect. Perceived organizational support reflects employees’ subjective perception of whether the organization values their contributions and cares about their well-being (Eisenberger et al., 2001). This study drew on social exchange theory (Blau, 1964) within the employee–organization relationship to suggest that employees’ awareness and expectations of exchanges with the organization may influence their work-related cognitions and attitudes. If employees feel that the organization provides them with sufficient support (e.g., skills training, improvement of working conditions, and welfare promotion), they may be more inclined to actively participate in work (Sun & Bunchapattanasakda, 2019). Furthermore, their perception of the organization may change, which consequently affects job satisfaction (Hancer & George, 2003) and well-being (Viot & Benraiss-Noailles, 2025). For hospitals, which are responsible for human organ donation and transplantation, organ donation may be part of the development goal system of the organization. When the perceived organizational support of a coordinator is strong, the negative impact of perceived risk on advice giving for organ donation may be suppressed because the coordinator is willing to invest more effort and promote the organization to complete more organ donations. Even if there is a certain risk of rejection, they may be willing to give advice to family members about organ donation, believing that the organization will respond positively to their actions. In addition, the positive effects of perceived obligation may be magnified when employees feel more organizational support, so that they form a positive psychological contract with the organization, believing it is worthy of their loyalty and devotion (Conway & Coyle-Shapiro, 2012). This psychological contract may lead them to be more willing to fulfill the responsibilities and obligations of the coordinator position, including giving advice and bearing the consequences. Thus, we proposed the following hypotheses:

Hypothesis 3a: Perceived organizational support will negatively moderate the effect of perceived risk on the advice‐giving behavior of organ donation coordinators.

Hypothesis 3b: Perceived organizational support will positively moderate the effect of perceived obligation on the advice‐giving behavior of organ donation coordinators.

This study recruited 316 organ donation coordinators from medical institutions in China to participate in a survey. The coordinators were specifically responsible for approaching families of potential donors, providing donation information, and facilitating the donation consent process. Among them, 101 (31.96%) were women and 215 (68.04%) were men; they ranged in age between 28 and 53 years (M = 42.95, SD = 5.93); and 189 (59.81%) held a master’s degree or higher, 122 (38.61%) held a bachelor’s degree, and five (1.58%) held a junior college qualification. We obtained ethical approval for the study from the Ethics Committee of NingboTech University, and all participants provided written informed consent prior to participation.

We measured transformational leadership using a 14-item scale developed by MacKenzie et al. (2001), which consists of four dimensions: core transformational leadership (four items, e.g., “Hospital leaders and I express a common vision”), high performance expectation (three items, e.g., “Hospital leaders demonstrate a great deal of expectations for the team”), individualized support (three items, e.g., “Hospital leaders take my feelings into consideration when they make decisions”), and intellectual stimulation (four items, e.g., “Hospital leaders cultivate my innovative thinking”). Responses are recorded on a 5-point Likert scale (1 = completely inconsistent, 5 = completely consistent). The scale demonstrated excellent internal consistency in this study, with a Cronbach’s alpha of .95.

 

We measured perceived risk using the five-item risk perception dimension from the scale developed by Babcicky and Seebauer (2017). A sample item is “I am worried about possible personal attacks.” Responses are recorded on a 5-point Likert scale ranging from 1 (completely inconsistent) to 5 (completely consistent). The scale demonstrated high internal consistency in this study, with a Cronbach’s alpha of .92.

 

We assessed perceived obligation by adapting four items developed by Eisenberger et al. (2001) to fit the context and characteristics of this study. A sample item is “I ensure that I can effectively persuade individuals to donate organs.” Responses are recorded on the a 5-point Likert scale ranging from 1 (completely inconsistent) to 5 (completely consistent). Internal consistency in this study was satisfactory, with a Cronbach’s alpha of .85.

 

We measured perceived organizational support by adapting six items from Eisenberger et al. (2001) to fit the specific context and characteristics of this study. A sample item is “The organization will be proud of my achievements in organ donation work.” Responses are recorded on a 7-point Likert scale ranging from 1 (completely inconsistent) to 7 (completely consistent). The scale demonstrated high internal consistency in this study, with a Cronbach’s alpha of .92.

 

We assessed advice giving using four items adapted from the Advice-Giving Intention Scale developed by Duan et al. (2019). A sample item is “I am willing to give advice to the family members of patients.” Responses are measured on a 5-point Likert scale ranging from 1 (completely inconsistent) to 5 (completely consistent). The scale exhibited high internal reliability in this study, with a Cronbach’s alpha of .92.

We included gender, age, and level of education as control variables, as prior research has shown that these demographic factors may influence coordinators’ advice-giving behavior (Uskun & Ozturk, 2013).

Table 1 presents the means, standard deviations, and bivariate correlation coefficients for all study variables. Transformational leadership was positively correlated with perceived obligation and advice giving. Perceived obligation also demonstrated a significant positive association with advice giving. In contrast, transformational leadership was negatively correlated with perceived risk, and perceived risk was negatively correlated with advice giving. No significant relationship was observed between perceived organizational support and advice giving, suggesting that perceived organizational support did not exert a direct effect on advice-giving behavior in this context, but may have functioned as an appropriate moderating variable. Overall, the observed correlations aligned with the theoretically expected relationships, providing preliminary support for subsequent hypothesis testing.

While the correlation analysis provided initial evidence supporting our hypotheses, it did not rule out the potential influence of other confounding factors. To partially address this limitation, we constructed a linear regression model, incorporating age, gender, and level of education as control variables to test the proposed hypotheses. The main effect regression results supported the overall model fit and credibility (see Table 2). Furthermore, transformational leadership exerted a significant positive effect on advice giving, thereby providing empirical support for Hypothesis 1.

The mediating roles of perceived risk and perceived obligation were further examined. As shown in Model 1 of Table 3, transformational leadership negatively predicted perceived risk. When we introduced perceived risk as a mediating variable (Model 2), the direct effect of transformational leadership on advice giving was reduced, indicating that perceived risk partially mediated this relationship. Similarly, the results of Model 3 demonstrated that transformational leadership positively predicted perceived obligation. When we included perceived obligation as a mediating variable (Model 4), the direct effect of transformational leadership on advice giving decreased, suggesting that perceived obligation also served as a partial mediator. These findings provided empirical support for Hypothesis 2.

Last, we examined the moderating role of perceived organizational support. After mean centering the variable of perceived risk, we created its interaction terms with both perceived obligation and perceived organizational support. As shown in Models 1 and 2 of Table 4, the interaction between perceived risk and perceived organizational support exhibited a significant negative effect on advice giving, whereas the interaction between perceived obligation and perceived organizational support demonstrated a significant positive effect. These results indicated that perceived organizational support exerted a dual moderating effect, strengthening the negative relationship between the perception of risk and advice giving, while amplifying the positive relationship between perceived obligation and advice giving. Thus, Hypothesis 3 was partially supported.

To further illustrate these effects, we generated interaction plots at one standard deviation above and below the mean of the moderator (M ± 1 SD), as presented in Figures 1 and 2. Simple slope analyses further revealed that for individuals with high perceived organizational support, the positive relationship between perceived obligation and advice giving was significantly strengthened (b = 1.15, p < .001), as was the negative relationship between perceived risk and advice giving (b = –1.26, p < .001).

This study drew on social exchange theory to examine the context of organ donation coordination within medical institutions. We developed a theoretical framework to elucidate the mechanisms by which subordinates provide advice to external stakeholders, as viewed through the lens of leadership style, and empirically tested the proposed hypotheses. The results indicated that transformational leadership significantly and positively predicted advice-giving behavior. Both perceived risk and perceived obligation served as partial mediators in this relationship. Our results suggested that transformational leadership reduced coordinators’ perceived risk while enhancing their perceived obligation, thereby increasing the frequency of advice giving related to organ donation.

 

Furthermore, the results revealed a nuanced moderating role of perceived organizational support. While this support amplified the beneficial effect of perceived obligation, it also intensified the negative relationship between perceived risk and advice-giving behavior. This indicates that under conditions of high organizational support, the inhibitory effect of perceived risk on professional conduct became more pronounced. This phenomenon can be explained by the emergence of performance expectancy pressure and heightened psychological accountability. In the high-stakes environment of organ donation, substantial organizational resources and support may lead coordinators to internalize a greater responsibility for successful outcomes. Thus, when faced with potential ethical or familial risks, coordinators with high perceived organizational support may exhibit increased risk aversion to avoid the higher professional and organizational costs associated with failure. These findings highlight the complex nature of perceived organizational support in shaping employee attitudes and suggest that the influence of support systems on professional behavior is contingent on the level of perceived professional risk (Pratiwi et al., 2023). 

First, leadership styles within medical institutions should be strategically optimized. Transformational leadership, characterized by its vision, charisma, and individualized consideration, exerts a profound influence on organizational development and the attainment of strategic objectives (Bass, 1995). Strengthening hospital leaders’ competencies in role modeling, fostering staff enthusiasm, and delivering personalized support is therefore imperative for advancing institutional effectiveness. Second, the incentive mechanisms for coordinators warrant systematic enhancement. Both material and nonmaterial incentives should be strengthened, with particular emphasis on nonmaterial (intrinsic) motivators to sustain coordinators’ internal drive for engaging in organ donation initiatives. Fostering a climate of organizational support for advice-giving behavior within hospitals may further mobilize coordinators’ work enthusiasm and commitment. Last, the professional competence of coordinators must be continuously improved. High standards of professional expertise and communication skills are essential to facilitating successful organ donation processes (Ismail et al., 2018). Efforts should be made to enhance coordinators’ communication capabilities, expand their knowledge base, and minimize potential misunderstandings or conflicts during interactions with the families of potential organ donors. 

This study has several limitations that warrant consideration. First, we examined the impact of transformational leadership on advice giving by focusing on individual-level variables; however, prior research has often conceptualized self-efficacy, which we did not incorporate into the present analysis, as a key individual-level construct (Blok et al., 2004; Symvoulakis et al., 2019). Second, although we acknowledged the role of sense of power, we did not examine it in depth. The extant literature has indicated that power can attenuate individuals’ perception of risk (Anderson et al., 2012), suggesting that sense of power may be an important antecedent or moderator in advice-giving behavior. Future research could therefore extend the current model by integrating self-efficacy and sense of power into the analytical framework, employing longitudinal or experimental designs to elucidate their mechanisms of influence and capture the dynamic interplay between leadership, psychological states, and advice-giving outcomes.

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Yuan Li, School of Business, NingboTech University, No. 1 Qianhu South Road, Yinzhou District, Ningbo City, Zhejiang Province, People’s Republic of China. Email: [email protected]