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Background: Burnout is very common and has significant negative outcomes for both nurses and patients. However, this literature has only recently begun to address the processes that explain why health care provider burnout leads to negative patient outcomes. This article extends that literature by examining how satisfaction with work processes impacts the link between nurse burnout and work-arounds.
Purpose: The purpose of this study was to examine the relationships between emotional exhaustion and potentially unsafe work practices (work-arounds) in the context of nursing administration of medication.
Methodology/Approach: The data were collected using online survey software and pencil-and-paper surveys returned directly to the researchers. The study was conducted among nurses in 2 acute care hospitals in the Midwestern United States. For one of the samples, data on work-arounds were provided by the nurses' supervisors. For the other sample, data were collected at a 6-month interval. The survey included measures of emotional exhaustion (the Maslach Burnout Inventory), work-arounds, and nurse satisfaction with medication administration processes.
Findings: We found that exhaustion was associated with greater use of work-arounds of medication administration processes. We also found that when nurses were more satisfied with the medication administration process, exhausted nurses were less likely to engage in work-arounds.
Practice Implications: The findings suggest that although exhaustion in nurses can lead to potentially unsafe practices, satisfaction with the work process can either exacerbate or reduce the problem.
Stress among health care professionals is very high, and its negative consequences (e.g., burnout) are a persistent concern in the health care industry (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002). As concerns for health care provider stress have grown, concerns for patient safety have grown in parallel, and it seems natural to consider the relationships between the two trends (Hickam et al., 2003). In particular, safety in medication administration has generated great interest (Institute of Medicine, 2006; Koppel, Wetterneck, Telles, & Karsh, 2008). A number of studies have already found that stress and burnout may exacerbate concerns about patient safety and lead to lower quality of care. For example, Shanafelt et al. (2009) examined error reporting among 7,905 surgeons and found that nearly 9% reported a major error in the last 3 months; those experiencing burnout were much more likely to have reported an error. In an earlier examination of physician stress, Firth-Cozens and Greenhalgh (1997) surveyed 225 English general practitioners and hospital physicians and found that 82 reported incidents where symptoms of stress had impacted patient care. Stress attributions included fatigue (57%), overwork (28%), depression or anxiety (8%), or the effects of alcohol (5%). There is a wealth of literature on burnout among nurses, suggesting that it is very common and has significant negative outcomes for both nurses and patients (Cimiotti, Aiken, & Poghosyan, 2008; Van Bogaert et al., 2010). However, this literature has only recently begun to address the processes that help explain why health care provider stress and burnout lead to negative patient outcomes (Williams, Lawrence, Campbell, & Spiehler, 2009). This article extends that literature by examining how satisfaction with work processes impacts the link between nurse burnout and potentially unsafe practices, termed work-arounds.
Work-arounds are processes that are undertaken to complete tasks when employees are faced with situations that keep them from doing the work in a way that they are expected to (Ash, Berg, & Coiera, 2004; Ash et al., 2003; Halbesleben, Wakefield, & Wakefield, 2008; Vogelsmeier, Halbesleben, & Scott-Cawiezell, 2008). For example, bar-code medication administration systems are susceptible to work-arounds because they introduce new steps in the work process that, although designed to improve patient safety, add additional workload to nurses' already hectic work lives (Yang, Boon-Yuen, Kankanhalli, & Yip, 2012). As a result, although their frequency is unknown, work-arounds appear to be increasing in frequency (Morath & Turnbull, 2005), including strategies such as making copies of patient code bracelets to keep near medication carts to speed up processing of medications (Morath & Turnbull, 2005; Wideman, Whittler, & Anderson, 2005). Work-arounds have also been observed in other systems, including medication dispensing systems (Azad & King, 2008), computerized order entry systems (Schoville, 2009), and payment systems (Hartmann, Hoff, Palmer, Wroe, Dutta-Linn, & Lee, in press). Work-arounds are a significant concern for health care organizations because they decrease the reliability of systems and create opportunities for errors (Kobayashi, Fussell, Xiao, & Seagull, 2005). We contend that work-arounds are more likely when employees experience high levels of burnout.
Burnout is a reaction to prolonged work stress that is characterized by emotional exhaustion, depersonalization, and reduced personal efficacy (Maslach, 1982). Emotional exhaustion refers to a feeling that one's emotional resources have been drained and he or she can give nothing further to work. Depersonalization is a process of detaching from the work; it is often considered a coping mechanism to deal with the emotional exhaustion. Finally, reduced personal efficacy refers to a perception that one is not as good at his or her job as he or she once was. In this study, we focused on emotional exhaustion as the primary marker of health care provider burnout. This is consistent with much of the recent literature on burnout, which has argued that emotional exhaustion is the "core" dimension of the burnout construct and the symptom most likely to appear first (Demerouti, Bakker, & Bulters, 2004; Shirom, 2003). Emotional exhaustion is of significant concern in nursing largely because it is so widespread among nurses and is associated with worse patient outcomes (Aiken et al., 2002). For example, Laschinger and Leiter (2006), in a study of 8,597 nurses, found that burnout was significantly associated with reduced patient safety, based on nurse reports of frequency of adverse events. As a result, it is good starting point for examining how depleted resources would lead to work-arounds.
The conservation of resources (COR) theory (Hobfoll, 1988, 1989, 1998, 2001) has become a popular theory in the stress and burnout literature and has seen a great deal of empirical support (Halbesleben & Buckley, 2004). The COR theory focuses on our psychological and physical resources, defined as objects, states, and conditions that we value (Hobfoll, 1988). The theory is built on two basic principles: that we seek to avoid loss of resources and that we invest resources to gain additional resources. The first principle suggests that when our resources are lost or threatened, we experience stress (Hobfoll, 1989); over the long-term, the repeated loss of resources could lead to psychological strain (Hobfoll & Freedy, 1993; Shirom, 2003). The second principle of the COR theory suggests that if we are to avoid strain resulting from resource loss, we need to invest our resources in ways that protect our current resources and hopefully lead to gains in resources over the long-term.
The second principle, resource investment, is the key principle for this study. In addition to suggesting that we invest resources to gain resources, Hobfoll (2001) proposed that (a) having more resources puts us in a better position to gain resources (a resource gain cycle), (b) having fewer resources leaves us more vulnerable to resource loss (a resource loss cycle; cf., Demerouti et al., 2004), and (c) when our resources are limited, we are more likely to take a defensive position in our resource investment strategies to first protect our current resources before attempting to gain more resources (see also Baltes & Baltes, 1990; Baltes, 1997). These three ideas give us further insight into the link between exhaustion and work-arounds.
Under the COR theory, emotional exhaustion is a situation of severely depleted work resources (Hobfoll & Freedy, 1993). As a result, the notions that resource loss cycles are more likely and that we are more likely to take a defensive posturing come into play. Halbesleben (2010) suggested that this would lead to a great reliance on work-arounds because it is easier for health care professionals to work around a block in the process than it is to correct the problem that is causing the block. Thus, a work-around requires fewer resources than correcting the problem that caused the block. When resources are limited, the COR theory, as well as empirical research, suggests that individuals will select the path that requires the fewest resources to get the job done; in the present case, it would likely be a work-around (Halbesleben, 2010; Hobfoll, 2001). Thus, we hypothesize:
Hypothesis 1: Emotional exhaustion is associated with higher use of work-arounds of medication administration systems.
Resource investment strategies are highly strategic; individuals invest their resources in ways that minimize their losses and maximize their gains (Hobfoll, 2001). As a result, individuals rationally consider the likelihood that their investments will be successful prior to choosing to invest in a certain course of action. In the context of medication administration, we argue that one's perceptions of the process used to administer medications will impact the likelihood of investing resources in working around the system rather than addressing the blocks in the system. Specifically, if the nurse is satisfied with the medication administration system, he or she may be more willing to invest resources in its improvement rather than bypassing the system to simply "get the work done." Satisfaction with the system implies a positive affective connection to the system and a greater desire to see its success. As a result, despite limited resources associated with exhaustion, one may be more willing to invest in process improvement rather than work around the system. On the other hand, if the nurse is dissatisfied with the system and has limited resources, there would be little perceived gain in investing in the process and a work-around would be the more likely response. Together, this suggests that satisfaction with the medication administration system moderates the positive relationship between exhaustion and work-arounds such that those who are satisfied are less likely to engage in work-arounds.
Hypothesis 2: The relationship between emotional exhaustion and work-arounds will be moderated by satisfaction with the medication administration system, such that greater satisfaction will reduce the strength of the positive association between exhaustion and work-arounds.
To test the hypotheses, we conducted a study with two samples of registered nurses. To provide a stronger test of the model, we used samples with different types of nursing experiences (temporary nurses vs. full-time/permanent staff nurses) and different medication administration processes (bar coding vs. no bar coding). If the psychological constructs were related, as the theory would suggest, these context factors should not impact the data, and thus, our findings should be replicated across the samples. Data collection in both samples was approved by the first author's institutional review board prior to data collection.
The participants in sample 1 were 104 registered nurses and their supervisors from an in-house temporary help pool for an academic medical center in the Midwestern United States. The nurses were primarily women (n = 85) and had an average age of 27.31 years (SD = 3.54 years). They had worked in the temporary help pool for a mean of 2.23 years (SD = 1.15 years), and they worked a mean of 26.11 hours (SD = 6.17 hours) per week. Although their assignments varied, 95 indicated that their current assignment involved direct patient care. At the time of the survey, the facility did not use a bar-code medication administration system.
The first author sent the surveys to the temporary nurses at their home addresses (because their work assignments varied); 138 surveys were distributed and 104 were returned, for a response rate of 75%. Demographic comparison of the respondents of the survey and those who did not respond, based on data provided by the administrators of the temporary help pool, indicated no significant demographic differences between respondents and nonrespondents.
The supervisors (n = 92) were also primarily women (n = 89). They had worked for the hospital an average of 5.14 years (SD = 2.87 years). Of the 92 supervisors, eight completed the survey for two temporary nurses; two supervisors completed the survey for three of the temporary nurses. The supervisor data were obtained by contacting all nursing supervisors in the hospital and asking them to complete a survey about each temporary nurse (from the temporary help pool) whom they supervised. With the exception of the demographic questions, all measures were completed about the temporary worker (e.g., the work-arounds of the temporary nurse, not the supervisor). The surveys were returned directly to the first author. A total of 125 surveys were distributed; five indicated that they did not supervise any temporary nurses, leaving a response rate of 77%. Demographic comparison of the respondents of the survey and those who did not respond indicated no significant demographic differences. Supervisor data were included to help verify self-report data and to address concerns about common method variance that may result from using data from a single source. They provided data only on the work-arounds they had observed of the participants.
The participants in Sample 2 were 243 registered nurses from a Level II trauma center in the Upper Midwestern United States. The sample included 23 men and 218 women (two participants did not respond to this question) with a mean age of 44.81 years (SD = 11.41 years). The participants had been working for their current organization for a mean of 12.79 years (SD = 10.59 years). They reported working a mean of 35.41 hours per week. The facility utilized a bar-code medication administration system; it had been launched about 6 months prior to Time 1 data collection.
The data were collected via an online survey. A survey link was sent by the director of nursing at the hospital with a request to participate in the survey. Three days after the initial recruitment e-mail to the nurses, the director of nursing sent a reminder e-mail encouraging them to participate. The hospital employs 398 registered nurses working in nonmanagement positions. Of those, 282 completed the survey, for an initial response rate of 71%. The data were collected at two time points about 6 months apart to reduce common method variance. The exhaustion measure was administered at Time 1; the work-around and medication administration measures were administered at Time 2. To track responses across data collections, participants were asked to provide an alphanumeric code that they derived from personal information that would be unknown by the researchers and not included in typical personnel files (e.g., first two letters of town of birth, last two letters of mother's maiden name, day of first child's birthday [00 was used for those who did not have a child], and last two letters of high school attended). This allowed us to match data while maintaining the anonymity of participants.
We were able to match data from the two data collections for 243 nurses (retention rate of 86%, final response rate of 61%). The retention rate of 86% across the 6 months was slightly better than the organization's retention rate for nurses during that period (82%). In addition to checking the demographic characteristics of the sample against those of their organization, we further tested for nonresponse bias by testing for differences in variables between participants who responded to the first round survey but not the second round survey. There were no differences on any Time 1 variables between Time 2 respondents and Time 2 nonrespondents.
To measure emotional exhaustion, we utilized the emotional exhaustion subscale of the Maslach Burnout Inventory-General Survey (Schaufeli, Leiter, Maslach, & Jackson, 1996). The emotional exhaustion subscale includes five questions that were scored on a 7-point frequency scale from never (0) to daily (6); a sample question is "I feel burned out at my work." The scale demonstrated acceptable reliability (internal consistency) in our study, with Cronbach's [alpha] values of .91 for Sample 1 and .90 for Sample 2. This is the most widely used measure of emotional exhaustion in the literature, with a vast literature supporting its validity (Halbesleben & Buckley, 2004).
Work-arounds were assessed using an adapted version of the measure of work-arounds in health care of Halbesleben and Rathert (2008). We adapted the four items to focus on medication administration. For example, "I have altered my work processes because of problems with technology" was changed to "When administering medications, I have altered my work processes because of problems with technology." Another sample item was "I have altered my work processes because the medication administration system is not designed well." Items were scored on a 7-point frequency scale from never (1) to every day (7). In Sample 1, this scale was completed by both the participant and his or her supervisor. The scale demonstrated acceptable reliability in our study, with Cronbach's [alpha] values for self-ratings of .87 for Sample 1 and .83 for Sample 2; the supervisor ratings had an internal consistency of .75.
Satisfaction with medication administration was assessed using the Medication Administration System-Nurses Assessment of Satisfaction scale of Hurley et al. (2006). It includes 18 items; a sample item was "The current medication administration system helps me to be more efficient at medication administration." Items were scored on a 5-point Likert-type scale from strongly disagree (1) to strongly agree (5); higher scores indicate greater satisfaction. The scale demonstrated acceptable reliability in our study, with Cronbach's [alpha] values of .95 for Sample 1 and .91 for Sample 2.
Because of its potential relationship with exhaustion, satisfaction with the medication administration system (particularly if participants had worked with a different system for a while), and work-arounds, we controlled for tenure with the organization in the analyses. It was assessed with a single question asking how long they had worked for the organization.
We tested our hypothesized model using the hierarchical regression procedures outlined by Baron and Kenny (1986) and Aiken and West (1991). Prior to running the regression models, we calculated the mean score for each of the variables. The interaction was calculated by multiplying the mean exhaustion score by the mean medication administration system satisfaction score for each participant. Then, we mean centered the independent and moderator variables, following the recommendations of Aiken and West (1991).
The first step in the regression added the control variable (tenure). The second step examined the relationship between exhaustion and work-arounds. Step 3 added the main effect of the moderator, satisfaction with medication administration. Finally, in Step 4, we added the interaction between exhaustion and satisfaction with medication administration. At each step, we analyzed the change in R2 and, if significant, examined the significance of the [beta] for the added variable.
Descriptive statistics from both samples, including means, standard deviations, internal consistency estimates (Cronbach's [alpha]), and correlations between the variables, are displayed in Table 1. As expected, emotional exhaustion was positively associated with work-arounds in both samples and satisfaction with the medication administration system was negatively associated with work-arounds in both samples. The regression results can be found in Tables 2 and 3. In Hypothesis 1, we predicted that exhaustion would be positively related to work-arounds. Examining the regression results in Tables 2 and 3, in particular Step 4 of each model, exhaustion was significantly and positively associated with self-rated ([beta] = .45, p < .01) and supervisor-observed ([beta] = .38, p < .01) work-arounds in Sample 1. In Sample 2, Time 1 exhaustion was significantly related to Time 2 work-arounds ([beta] = .59, p < .01). Thus, Hypothesis 1 was supported.
With Hypothesis 2, we predicted that satisfaction with medication administration moderated the relationship between exhaustion and work-arounds. In both samples, we found that the addition of the interaction between satisfaction with medication administration and exhaustion led to a significant increase in R2 (Tables 2 and 3). Again examining Step 4 in Tables 2 and 3, we found that the interaction between satisfaction with medication administration and exhaustion was significant for both self-rated ([beta] = -.19, p < .01) and supervisor-observed ([beta] = -.28, p < .01) work-arounds in Sample 1. The interaction was also significant in Sample 2 ([beta] = -.30, p < .01).
To illustrate the moderation effects, we graphed the interactions (Figures 1 and 2) using the procedures outlined by Aiken and West (1991) and Preacher, Curran, and Bauer (2006). We also performed simple slope tests (Aiken & West, 1991) to examine whether the slopes depicted in Figures 1 and 2 were significantly different from zero. The simple slope tests indicated that the slopes were positive (e.g., significantly greater than zero) in each case (Sample 1, self-rated work-arounds: low satisfaction, [beta] = .55, p < .01; high satisfaction, [beta] = .28, p < .05; Sample 1, supervisor-rated work-arounds: low satisfaction, [beta] = .49, p < .01; high satisfaction, [beta] = .21, p < .05. Sample 2, low satisfaction, [beta] = .64, p < .01; high satisfaction, [beta] = .36, p < .01). The pattern depicted in Figures 1 and 2 is consistent with the predictions-there is a main effect for exhaustion (exhaustion is positively associated with work-arounds) but that effect is diminished among those who are higher in satisfaction with the medication administration system. Overall, the findings support Hypothesis 2.
In two samples of acute care nurses, we found that exhaustion was associated with a greater use of work-arounds of medication administration systems. Further, we found a weaker relationship between exhaustion and work-arounds for nurses who were satisfied with the medication administration system. These findings were consistent across both samples, across 6 months in one of the samples, and using supervisor-observed work-arounds in the other sample.
These findings have important implications for understanding utilization of medication administration systems in light of employees' investment of their dwindling resources. Satisfaction with the medication administration system appears to be a mechanism that creates a greater priority on utilizing the system as it was intended (in other words, not working around perceived blocks) despite having limited resources to work with. From a COR theory perspective, this suggests that it is possible to break resource loss cycles if one directs his or her resources into something he or she feels positive about.
Our findings are consistent with the work of Tucker (2004) and Tucker and Edmondson (2002, 2003), who suggested that simple solutions to problems at work (of which work-arounds are an example) can often lead to additional problems and do little to address critical operational failures that lead to error (Halbesleben, Savage, Wakefield, & Wakefield, 2010). As resources are limited, employees may, out of necessity, turn their attention to simply getting the work done ("single-loop" problem solving) rather than carefully considering the underlying causes of the blocks they encounter and engaging in collaborative problem solving to eliminate those blocks ("double-loop" problem solving), depending on the severity of the block. To some extent, this problem can be attributed to leadership, which may facilitate cultures of collaboration or cultures of blame. Tucker and Edmondson (2003) reported that 70% of nurses they interviewed believed that their managers expected them to solve everyday problems by themselves, and potentially engage in a work-around, to address or risk being perceived as being incompetent.
That said, we acknowledge that we have investigated only the single-loop aspect of problem solving in the form of work-arounds and the drained resources associated with exhaustion. Extending our arguments would suggest that if employees had excess resources, they would invest those resources in problem-solving behaviors that address blocks in work flow. That remains an empirical question about which additional research is needed. Because the absence of exhaustion does not imply the presence of engagement (in other words, not lacking resources does not mean one has a surplus of them), we cannot know for sure from our study how those excess resources would be invested.
We acknowledge that there are some limitations to this study that need to be considered when interpreting the results. The data from Sample 1 were cross-sectional, limiting our ability to draw causal conclusions and increasingly the likelihood that common method biases influenced the results. These limitations were mitigated by the use of supervisor ratings of work-arounds in Sample 1 and longitudinal data in Sample 2. Although the single-source nature of the data from Sample 2 means that common method bias is still a potential concern, the 6-month time lag reduces this concern somewhat (Podsakoff, MacKenzie, Lee, & Podsakoff, 2003).
Our study is limited to nurses from two acute care facilities, making generalizability unknown. Variability in medication administration processes may make results difficult to generalize as nurses may react differently to different processes and work-arounds of the medication administration processes may vary in their likelihood (e.g., it may be more or less difficult to work around some processes, particularly where forcing functions limit the way the system is used). As a result, replication in other settings (e.g., nursing homes) and facilities where other types of medication administration systems are used would add to the external validity of our findings. Further, we do not know the impact that asking the director of nursing to solicit participants has on the data; however, using a different approach for both samples and finding the same results suggests that it was unlikely to be a major factor. Further, that the nurses reported work-arounds in that sample at a higher rate than the first sample suggests they were not "holding back" to manage impressions.
Finally, we acknowledge that there are other confounding factors that may influence a nurses' decision to follow a designated medication administration process rather than working around it. For example, we have not captured nurse workload or patient acuity, which could factor in to such decisions. However, that our model held despite our not accounting for these variables suggests that, although potentially important, they were not necessarily a major driver of the constructs in the model.
Our findings suggest that efforts need to be taken to reduce exhaustion among employees and improve satisfaction with the medication administration system. Based on our findings, both of these approaches could reduce the frequency of work-arounds in medication administration. There is a common denominator supporting both reducing exhaustion and improving satisfaction with a work process: support. In the case of medication administration systems (and clinical information systems broadly), one form of support that improves implementation and satisfaction with system is the use of super users, or individuals who have additional expertise in the system and can serve as a resource for other users (Halbesleben, Wakefield, Ward, Brokel, & Crandall, 2009; Wetterneck, Skibinski, Schroeder, Roberts, & Carayon, 2004; Wideman et al., 2005). On the basis of our findings, we suggest that organizations consider developing super users who can not only improve satisfaction with medication administration systems but also serve as a more general mechanism for support in the workplace (thus reducing exhaustion).
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