A study of unreasonable illegitimate tasks, administrative tasks, and sickness presenteeism amongst Norwegian physicians: an everyday struggle?

A study of unreasonable illegitimate tasks, administrative tasks, and sickness presenteeism... Background: It has been shown that a recently defined stressor, ‘illegitimate tasks’, has negative effects on employees’ work motivation and health. Better understanding of the illegitimate tasks undertaken by physicians might contribute to a more resource-efficient division of labour within the health care system, with beneficial effects on organisational economics and employee performance. We aimed to investigate the prevalence of unreasonable illegitimate tasks, their associations with workplace variables and their impact on health, in particular sickness presenteeism. Methods: Cross-sectional data were collected in 2012. A sample of 545 Norwegian physicians answered an online questionnaire. The response rate was high (71.8%). The data were analysed using independent-samples t-tests, ANOVA and logistic regression. Results: About 50.2% of physicians in all clinical positions reported that at least 11% of their everyday tasks could have been done by other hospital personnel. Seven percent of the physicians reported that at least 31% of their daily workload consisted of unreasonable illegitimate tasks. There were no significant differences in unreasonable illegitimate tasks according to clinical position, age or gender. Administrative task load and role conflict were positively associated with unreasonable illegitimate tasks that physicians reported could be reallocated to non-medical professionals. Moreover, unreasonable illegitimate task was associated with a higher probability of sickness presenteeism after controlling for age, gender, role conflict, control over work pace, exhaustion and administrative tasks. Conclusions: The results confirm that physicians’ workload includes a high proportion of unreasonable illegitimate tasks and that this can contribute to sickness presenteeism. Investigation of work environmental factors can provide insight into the mechanisms behind unreasonable illegitimate tasks. Decreasing the amount of administrative tasks and role conflicts faced by physicians should be a priority. These findings could be used to make hospital task management more resource-efficient. Our results indicate that a substantial proportion of physicians’ work capacity could be re- allocated to core tasks. Further research is needed into the specific type and content of unreasonable illegitimate tasks undertaken by physicians in order to determine to whom they should be allocated to ensure a healthy and motivated workforce and provision of high quality, resource-efficient health care services. Keywords: Administrative tasks, Exhaustion, Physicians, Role conflict, Sickness Presenteeism, Unreasonable illegitimate tasks * Correspondence: lise.lovseth@ntnu.no Department of Research and Development, Division of Psychiatry, St. Olavs Trondheim University Hospital, Trondheim, Norway Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Thun et al. BMC Health Services Research (2018) 18:407 Page 2 of 9 Background them away from their core task, which is medical treat- It has been shown that a recently defined stressor related ment, whereas a hospital orderly would see the same task to improper use of work time, termed ‘illegitimate tasks’ as part of his or her daily work [4]. At the theoretical level [1, 2], is related to stress and well-being at work [3–7]. it has been argued that unreasonable and unnecessary Findings from both Europe and the US have been pub- illegitimate tasks should be treated as separate constructs lished [1, 4, 8, 9], but findings on illegitimate tasks and [8]. In this study we investigate reports of unreasonable their relationship with stress outcomes need to be vali- illegitimate tasks. Unreasonable illegitimate tasks are con- dated in samples from different cultures and occupational sidered the main facet of illegitimate task and deserve groups [1, 2, 10]. In addition, because organisations and research attention because of their association with work employees aim to minimise the frequency of illegitimate engagement and time pressure [14]. tasks, there is a need to explore possible antecedents of Physicians can be described as cost-generating profes- illegitimate tasks [4]. Efficiency has for many years been a sionals because they have high salaries and demand add- key policy goal in many Western countries [11]and itional treatment resources [15], so it is inefficient to increased knowledge about the extent and content of the have physicians carrying out tasks that could be per- illegitimate tasks undertaken by physicians would help to formed by others and it has been suggested that research improve the efficiency of health services. There is evidence into the medical profession’s experience of illegitimate that there has been an increase in the proportion of work tasks is needed [3]. Physicians’ perception of illegitimate time that physicians spend on non-core tasks [12], raising tasks can depend on a variety of factors within their concern that physicians’ time is not being used appropri- work context [16]. Ahmned, Eatough, and Ford [17] ately. This inappropriate use of physicians’ work time can found national variations in illegitimate task burden and be associated with performance of illegitimate tasks. To outcomes of undertaking illegitimate tasks. This study our knowledge there has not yet been any systematic investigated physicians at a Norwegian university hos- investigation of the proportion of physicians’ workload pital. As part of the public health care system, hospitals that is made up of unreasonable illegitimate tasks. The are owned by the government, run by regional health aim of this study was to investigate the prevalence of un- authorities and publicly funded as part of the national reasonable illegitimate tasks, associated psychosocial work budget. Part of hospitals’ income is activity-based, but environment factors and one health-related outcome physicians are permanent employees with fixed salaries. amongst physicians working in a hospital setting. General practitioners are self-employed, but publicly financed, partly on a fee-for-service basis. In addition Theoretical background Norway has a strong Work Environment Act and strong Illegitimate tasks, defined as work tasks that are not re- employment protection legislation. There is also a rela- lated to one’s core occupation or that one perceives as tively low power distance between employees and em- inappropriate and a waste of time, are an emerging issue ployers in Norway [18]. Power distance is the degree to in occupational stress research [2, 7]. If an employee which less powerful members of a society are comfort- perceives that a work task should have been carried it able with the unequal distribution of power and recog- out by others, or if it violates norms about expected nise it as legitimate [18]. In Norway, as in many other work tasks or challenges his or her professional identity countries, there has been a change in task management then it is considered illegitimate [1, 2]. The concept of il- and an increase in the amount of work time spent by em- legitimate tasks is derived from the stress-as-offense-to-self ployees on additional tasks and administration. Accord- (SOS) theoretical framework, which posits that being ingly, it is possible that illegitimate tasks are experienced assigned an illegitimate task may trigger stress reactions as a threat to time spent on core tasks. [1], based on Lazarus’s[13]assumptionthat stress isre- Health care workers, including physicians, report lated to threats to important goals. There are two types of spending increased amounts of time on meetings, illegitimate tasks: unnecessary and unreasonable [1, 2, 7]. administration, measurement and reporting rather than Unnecessary illegitimate tasks are defined as tasks that are working with patients [3, 12, 19]. The growing number perceived as a waste of time and need not be done by any- of administrative tasks diverts time and attention away one, and tasks that could have been avoided or carried out from more clinically important activities [19]. These ad- with less effort if things were organised more efficiently [2], ministrative tasks are not unnecessary, but are likely to e.g. transferring patient data manually because two techno- fall - to some extent - outside of the range of tasks phy- logical systems are incompatible. Unreasonable illegitimate sicians consider part of their professional role. Hence tasks are tasks that are outside one’s occupational role and there is a need to explore how administrative burden conflict with specific aspects of one’s role or occupational relates to reports of illegitimate tasks. A better under- status [2], e.g. physicians asked to transporting a bedbound standing of illegitimate tasks should make it possible to patient are likely to criticise the organisation for taking make better decisions about task assignment [7] and Thun et al. BMC Health Services Research (2018) 18:407 Page 3 of 9 task management. Ahmed et al. [17] highlighted the risk demands-resources model [33, 34] provides a theoret- that as a result of increased focus on the economic ical framework which explains why unreasonable growth, employees will find themselves assigned more illegitimate tasks may be associated with sickness present- tasks, including administrative tasks, that fall outside eeism. Unreasonable illegitimate tasks may be considered their formal job role. More knowledge of the correlates job demands, as it requires effort to carry them out and of illegitimate tasks should enable organisations to they impose demands on individuals who do so [7]. It is reduce their number [10] or find ways to manage them possible that in a bid to cope with the pressure of unrea- in a more resource-efficient manner. sonable illegitimate tasks, physicians use sickness presence As illegitimate tasks have been shown to act as a job as a strategy for coping with their high workload and so stressor it is important to investigate how they affect the relationship between unreasonable illegitimate tasks physicians’ health and well-being [4, 7, 20]. Previous and sickness presenteeism should be investigated [3]. research has shown that illegitimate tasks are negatively A high prevalence of tasks perceived as illegitimate can related to job satisfaction [4, 6] and positively related to imply that an organisation would benefit from allocating counterproductive behaviour [2] and stress reactions resources differently. As previous research on illegitimate among employees [21]. One study found that participants tasks has reported that they have consequences for both who experience a high burden of illegitimate tasks had individuals and organisations, there is a need for studies of higher levels of the stress hormone cortisol than peers the prevalence of illegitimate tasks in different professions dealing with fewer illegitimate tasks [22]. In addition, [2, 4, 7]. Although there have been advances in research illegitimate tasks have been shown to reduce sleep quality on illegitimate tasks studies of the relationships between [23], and have been prospectively associated with lower illegitimate tasks, workplace correlates and health-related mental health [5] as well as being correlated with negative outcomes are scarce [4, 9]. A job characteristic associated affect and low self-esteem at the end of the working day with illegitimate tasks, especially unreasonable illegitimate [8]. Illegitimate tasks have also been found to be strongly tasks, is role conflict, defined as lack of congruent expec- associated with strain outcomes, such as feelings of resent- tations and demands from other people in the workplace ment towards one’s organisation and irritability, over a [35, 36]. As the concepts of role conflict and illegitimate period of 2 months [7], and have been related to turnover tasks are highly related but distinguishable from each intention [10]. Overall, previous research indicates that other, it is important to control for role conflict in re- illegitimate tasks have negative consequences for both in- search on illegitimate tasks [1, 2, 7]. In addition, perform- dividuals and organisations, but none of these studies has ance of work tasks that are outside their core role or job looked at the experiences of physicians. We argue that in definition has been associated with stress and ill health in order to improve our understanding of unreasonable il- physicians [19, 37]. Investigating the relationship between legitimate tasks it is important to study the phenomenon unreasonable illegitimate tasks and health outcomes is im- in a specific profession, as illegitimate tasks are a specific, portant, as physicians’ ill health can indirectly or directly task-related stressor that constitutes a threat to one’s affect the quality of health care and patient safety [38–40]. professional identity [7, 9]. Based on the theoretical framework and review of pre- The SOS theoretical framework implies that being vious findings, the aim of this study was threefold: 1. To expected to undertake illegitimate tasks can increase the investigate what proportion of working time hospital risk of poor health amongst physicians. Performing il- physicians think they spend on unreasonable illegitimate legitimate tasks requires emotional and physical effort tasks and how this varies with clinical position, gender, and may induce symptoms of strain [7]. Cognitive, age and reported administrative workload. 2. To analyse affective and physical strain may result in exhaustion the relationship between unreasonable illegitimate tasks [24], and exhaustion has been shown to correlate with and reported administrative work amongst physicians illegitimate tasks [3, 7, 25]. Exhaustion has also been whilst controlling for variance in role conflict, gender shown to have a reciprocal relationship with sickness and age. 3. To describe the relationship between unrea- presenteeism [26], defined as attending work when ill sonable illegitimate tasks and sickness presenteeism in [27]. Amongst physicians strain and ill health often physicians after controlling for variance in age, gender, manifest as sickness presenteeism [28–30], which has been role conflict, control over work pace, exhaustion and shown to be prevalent among physicians [28, 30, 31]. Physi- administrative tasks. cians often go into work when they are ill, because of their high work load, the lack of a replacement, responsibility Method and their crucial role in hospitals’ main task, which is Participants and procedure medical treatment [28, 30, 32]. Illegitimate tasks can be The study is based on survey data from a sample of regarded as stressors that can contribute to strain and Norwegian university hospital physicians participating in a variety of negative health outcomes [21]. The job a study concerning work-related health, organisational Thun et al. BMC Health Services Research (2018) 18:407 Page 4 of 9 culture and working conditions amongst European phy- reference category. Age was captured using nine age sicians (HOUPE study, phase II). We conducted a categories: ≤ 29 years (1); 30–34 years (2); 35–39 years web-based survey, in English, between February and (3); 40–44 years (4); 45–49 years (5); 50–54 years (6); May 2012. Participants received a letter describing the 55–59 years (7); 60–64 years (8) ≥ 65 years (9). study and containing a link to the questionnaire; they provided their responses anonymously. The participants Administrative/management tasks were qualified physicians and in full- or part-time em- The respondents were asked to report the percentage of ployment at the time of data collection. The project was their work time that was taken up by management and approved by the hospital board, the union representa- administration tasks. tives of the physicians at the hospital and the Regional Ethics Board. As well as sending out an email giving Role conflict information about the project, the research team also Role conflict was measured using three items from the gave short, oral presentations to all departments and General Nordic Questionnaire for Psychological and clinics at appropriate meetings. Participation was volun- Social Factors at Work (QPS Nordic) [41]. The selected tary and the online survey could not be accessed until items deal with conflicts between demands and re- consent to participation had been provided. The re- sources, conflicting requests and conflicts between the sponse rate was 71.8% (N = 545/759). Just under half the subject’s expectations and external demands [42]. participants (45%, n = 245) were female physicians. An Example item: “How often do you receive incompatible analysis of non-respondents showed that the sample was requests from two or more people?” Responses were representative of all physicians of the hospital in terms given on a five-point scale ranging from “very seldom or of age, gender, and position. never” (1) to “very often or always” (5). Cronbach’s alpha for this scale (α = .68) corresponded to the validation Measures data on QPS Nordic [41, 42]. A high score indicates high The questionnaire included 123 items on education, role conflict. work-related health, organisational culture and working conditions. Here we report on the variables relevant to Control over work pace our objectives: illegitimate tasks, role conflict, control We measured control over work pace with four items over work pace, amount of administrative tasks, exhaus- from the QPS Nordic [42] dealing with control over tion and sickness presenteeism. work pace, decisions about the timing and length of breaks and decisions about working hours (flexitime). Unreasonable illegitimate tasks Responses were given on a five-point scale ranging from The proportion of physicians’ workload made up of “very seldom or never” (1) to “very often or always” (5). unreasonable illegitimate tasks was measured by the Cronbach’s alpha for the scale (α = .83) corresponded to item “In your opinion, what proportion of the tasks you the validation data on QPS Nordic. deal with every day could be done by other hospital personnel (non-physicians)?” The response options were: Exhaustion none (coded 1); 5–10% (2); 11–20% (3); 21–30% (4); Exhaustion was measured using five items from the ≥31% (5). The data from the ordinal variable were Oldenburg Burnout Inventory (OLBI) [24](α = .73). The recoded into a binary variable: low level of unreasonable measure included both positively and negatively worded illegitimate tasks (0 = 0–10%) and high level of unrea- items (revised). Example item: “After work I usually feel sonable illegitimate tasks (1 = ≥11%) to enable analysis of worn out and weary”. Responses were given using a mean differences in work environment factors on the four-point Likert scale ranging from “totally agree” (1) to basis of level of unreasonable illegitimate tasks. The “totally disagree” (4). High scores on the burnout mea- cut-off between low and high level of unreasonable illegit- sures indicate a feeling of exhaustion. imate tasks was based on Eatough et al.’s[9]findingsthat illegitimate tasks can occur several times within a work- Sickness presenteeism day, with an average of 2 and 3 such tasks per week. This was measured with two questions: “Have you gone to work with an illness in a situation where you would Personal characteristics have recommended a patient to stay at home?” followed Participants were asked to describe their current clinical up by “How often has this happened during the last 12 position using one of the following categories: resident months?” [29]. Responses were coded as follows: none doing specialist training (1), specialist/consultant/medical (1), once (2), 2–4 times (3) and > 5 times (4). Employees officer (2), chief physician/senior medicalofficer/director were classified as showing sickness presenteeism if they (3) or other (4). Gender was coded with male (1) as the had attended work whilst ill as least twice during the Thun et al. BMC Health Services Research (2018) 18:407 Page 5 of 9 previous 12 months [43]. The variable was dichotomised gender and age. The results from the logistic regression as regular attendance (0) and sickness presenteeism (1). are summarised in Table 3. There was a positive rela- tionship between unreasonable illegitimate tasks and Statistical analyses amount of administrative tasks (b = .03, p < .001). In The illegitimate tasks variable is reported as a percent- terms of interpreting the findings it is important to note age and frequency. One-way ANOVA was used to assess that administrative tasks are coded in terms of percent- differences in illegitimate task load on the basis of clin- age of working time meaning that the unstandardised ical position. Independent samples t-tests (two-tailed) coefficient reflects an increase of 1 %. Criteria set out by were used to assess mean differences between psycho- Cox and Snell and Nagelkerke [45] show that the logistic social strain variables in participants with low and high model explained between 10.4 and 13.9% of the variance loads of illegitimate tasks. Logistic regression models in illegitimate tasks. These findings indicate that physi- were used to describe correlates of illegitimate tasks and cians who have a high administrative task load and experi- illegitimate tasks as a correlate of sickness presenteeism. ence conflict are also likely to report a high unreasonable We confirmed that the data met the requirements for illegitimate task load. logistic regression analysis [44, 45]. SPSS version 24 was The analyses show that there were systematic differ- used for the analyses. ences in psychosocial variables based on unreasonable illegitimate task load. Participants with a high unreason- Results able illegitimate task load experienced greater role conflict Descriptive statistics (M =2.82, SD = 0.75) than participants with a low unrea- Table 1 presents means, standard deviations and correla- sonable illegitimate task load (M =2.44, SD =0.80, t tions between the variables. The bivariate correlations (534) = 5.62, p < 0.001). This was a medium effect indicated positive associations between unreasonable (Cohen’s d = 0.49). Sickness presenteeism was greater illegitimate tasks and role conflict (r = .20, p < 0.001), in participants with a high unreasonable illegitimate and sickness presenteeism (r = .12, p < 0.01). The variable task load (M = 2.61, SD = 0.85) than participants with a low most closely associated with unreasonable illegitimate unreasonable illegitimate task load (M =2.34, SD = 0.91, tasks was administrative workload (r = .23, p < 0.001). t (535) = 3.57, p < 0.001). This was a medium effect The variable most associated with sickness presenteeism (Cohen’s d = 0.31). These results show that a high un- was exhaustion (r = .27, p < 0.001). reasonable illegitimate task load is more stressful than The question of whether unreasonable illegitimate a low unreasonable illegitimate task load. tasks was prevalent amongst physicians was explored. Finally, we hypothesised that unreasonable illegitimate Table 2 shows that 50.2% physicians reported that at tasks would be related to sickness presenteeism after least 11% of their everyday tasks could have been done controlling for variance in age, gender, role conflict, con- by other hospital personnel. Approximately 7% of the trol over work pace, amount of administrative tasks, and physicians reported that at least 31% of their workload exhaustion. The results from the logistic regression are consisted of unreasonable illegitimate tasks. There were summarised in Table 4. They indicate that the unreason- no mean differences of unreasonable illegitimate tasks able illegitimate tasks variable was a positive predictor of according to clinical position, age or gender. Table 2 sickness presenteeism. The OR for unreasonable il- shows data on physicians’ unreasonable illegitimate tasks legitimate tasks was 1.69 (p < 0.01), indicating that, on among all physicians and based on their current clinical average, a physician who reports a high load of unrea- position. sonable illegitimate tasks had an OR for sickness pres- We also analysed the associations between unreason- enteeism of 1.69. Exhaustion had the highest OR value able illegitimate tasks and amount of administrative (OR =1.81, p < 0.001), indicating that as level of ex- tasks after controlling for variance in role conflict, haustion increases the probability of attending work Table 1 Means (M), Standard Deviations (SD), and Correlations between the study variables Measure M (SD) 123 4 56 1. Unreasonable illegitimate Work Task 2.66 (1.08) – 2. Administrative Task 20.27 (18.14) .23** – 3. Role Conflict 2.64 (0.80) .20** .06 – 4. Control over Work Pace 2.76 (0.94) .04 .15** −.20** – 5. Exhaustion 2.48 (0.60) .05 .04 .32** −28** – 6. Sickness Presenteeism 2.47 (0.89) .12* .03 .17** −24** .27** – *p < .01 **p < .001 Thun et al. BMC Health Services Research (2018) 18:407 Page 6 of 9 Table 2 Physicians’ unreasonable illegitimate task load as a Table 4 Predictors of sickness presenteeism among physicians percentage of task load (n = 538) Variable b Wald OR 95% CI for OR Unreasonable All Employees Residents Specialists Others Unreasonable illegitimate Tasks 0.53* 6.69 1.69 [1.14–2.52] illegitimate n (%) n (%) n (%) n (%) Role Conflict 0.08 0.33 1.08 [0.83–1.40] Work Tasks Control over Work Pace −0.44** 15.48 .64 [0.52–0.80] None 69 (12.6) 28 (13.5) 41 (14.2) 2 (4.8) Exhaustion 0.59** 11.24 1.81 [1.28–2.55] 5–10% 194 (35.5) 79 (38.2) 103 (35.6) 12 (28.6) Administrative Tasks 0.004 0.55 1.00 [0.99–1.02] 11–20% 166 (30.3) 65 (31.4) 85 (29.4) 16 (38.1) Gender 0.02 0.006 1.02 [0.69–1.50] 21–30% 71 (13.0) 21 (10.1) 42 (14.5) 8 (19.0) Age −0.07 0.93 [0.85–1.02] 31% or more 38 (6.9) 16 (7.7) 18 (6.2) 5 (11.9) -2log likelihood 619.37** Total n 538 (98.4) 207 289 42 Cox & Snell R .107 Nagelkerke R .144 Note. *p < .05, **p < .001 whilst sick also increases. The OR for control over work pace was 0.64 (p < 0.001), indicating that as control over work pace increases the probability of at- In more detail, this study showed that 50% of all physi- tending work whilst sick decreases. Criteria set out by cians reported that more than 10% of their daily task Cox and Snell and Nagelkerke [45] indicated that the load consisted of unreasonable illegitimate tasks, i.e. logistic model explained between 10.7 and 14.4% of tasks that could have been done by other hospital staff. the variance in sickness presenteeism. This finding is consistent with Aronsson and colleagues’ [3] suggestion that physicians spend time on tasks that Discussion are not part of their professional role. Our results indi- This study has shown that Norwegian hospital physicians cate that a substantial proportion of physicians’ work have a high unreasonable illegitimate task load, as 50.2% of capacity could be re-allocated to core tasks. On the basis the participants reported that at least 11% of their task load of our results we estimate that between 8 and 13% of consisted of unreasonable illegitimate tasks on a daily basis. daily physician resources could be re-allocated. It follows Approximately 7% of the physicians reported that at least that re-allocation would increase total use of resources, 31% of their daily work tasks were unreasonable illegitimate as employees in other roles would have to compensate tasks. Another main finding is that a high unreasonable for the loss of physician resources to ensure that these illegitimate task load was more stressful than a low unrea- tasks continue to be performed effectively, but since sonable illegitimate task load. Participants with a high physicians can be regarded as a scarce resource, redu- unreasonable illegitimate task load reported a higher pro- cing the time they spend on illegitimate tasks should be portion of administrative tasks and more role conflict than considered a more efficient allocation of resources. participants with a low unreasonable illegitimate task load. It seems likely that the tasks physicians define as unrea- In addition, participants with a high unreasonable illegitim- sonable and illegitimate are tasks outside their field of ex- ate task load were more likely to attend work whilst sick pertise and therefore more appropriate to other (health) than colleagues with low unreasonable illegitimate task personnel. For instance, re-allocating administration of loads. Moreover, the findings indicate that unreasonable il- intra-vitreal injections from physicians to nurses was legitimate tasks and exhaustion both increase the likelihood shown to be a resource-efficient usage of personnel that of sickness presenteeism among physicians, whereas a high enabled hospitals to cope with an increase in physicians’ control over work pace appears to decrease the odds of workload. DaCosta and colleagues [46]together with physicians attending work whilst sick. Michelotti and colleagues [47] suggested that skill mix (changing professional roles) [48] is beneficial, acceptable Table 3 Predictors of unreasonable illegitimate tasks amongst to patients, and an effective use of resources. The effect- physicians iveness of skill mix across professions remains relatively Variable b Wald OR 95% CI for OR unexplored [49] and the likely consequences of skill mix Administrative Tasks 0.03* 21.41 1.03 [1.02–1.04] change need to be explored [48]. It is important that fu- Role Conflict 0.64* 25.40 1.77 [1.48–2.43] ture research should investigate the extent to which skill mix can reduce illegitimate task loads (in a hospital con- Gender −0.80 0.15 0.92 [0.63–1.36] text) or contribute to more efficient use of staff resources. Age −0.06 1.28 0.95 [0.86–1.04] At the same time, future research should identify which -2log likelihood 630.21* work tasks physicians consider illegitimate and why,as Cox & Snell’s R .104 Nagelkerke’s R .139 well as exploring how such tasks could be made attractive Note. *p < .001 to physicians or other health professionals. Thun et al. BMC Health Services Research (2018) 18:407 Page 7 of 9 At this point it is important to consider whether the pressure that contributes to a conflict between looking tasks that physicians perceive as illegitimate for a phys- after one’s own health and caring for one’s patients. Phy- ician really are. For instance, in many professions admin- sicians may feel under pressure to attend work when istrative tasks are increasingly a part of the job they are ill because it is patients who suffer when they description [12]. Administrative tasks might be perceived spend time on unreasonable illegitimate tasks or are ab- by physicians as illegitimate because they are not directly sent because of sickness. Another explanation is that related to clinical treatment. We found a positive associ- physicians attend work whilst ill in order to compensate ation between high amount of administrative tasks and for high workload [3]. In the long run compensatory unreasonable illegitimate task load amongst physicians sickness presenteeism can be counterproductive and after controlling for variance in role conflict. One poten- should be avoided, as it could damage the individual, tial approach to reducing physicians’ perceived amount colleges and the organisation [3]. Physicians are known of unreasonable illegitimate tasks would be to focus on to have high rates of sickness presenteeism [28–30], and their administrative workload or provide them with the our findings suggest that the risk of physicians attending tools they need to manage these tasks more efficiently work whilst sick could be reduced by reducing their un- [19]. As previous research has shown that a high admin- reasonable illegitimate task load and level of exhaustion istrative burden causes negative affect and prevents phy- or increasing their control over their work pace. sicians from putting patients first [12], it is important to address and adjust administrative tasks that are per- Limitations ceived as unreasonable and illegitimate. According to Although the results provide support for the study hy- the SOS theoretical framework, expecting employees to potheses the cross-sectional design means that we cannot perform illegitimate tasks is an active violation of the make causal inferences. However, as previous studies have psychological contract between employer and employee, indicated that illegitimate tasks predict strain, it is plaus- as illegitimate tasks disturb norms and rules associated ible to suggest that unreasonable illegitimate tasks trigger with a profession [1, 4, 7]. Illegitimate tasks threaten sickness presenteeism rather than the other way around. professional identity and are therefore particularly The consequences of illegitimate tasks should be investi- stressful [7]. Thus, being subjected to a high administra- gated through longitudinal research. Common method tive work load and role conflict may make physicians variance is a potential problem for our study because all more likely to perceive tasks as illegitimate, because the variables were self-reported. But self-reports are prob- such tasks fall outside their contracted work or profes- ably the most appropriate source of data on illegitimate sional role. Björk and colleagues [4] found that the fol- tasks as the judgement about legitimacy is a matter of lowing organisational variables were positively associated individual perception and experience [25]. Generalisability with managers’ reports of illegitimate task load: internal is also an issue, as studies often have single samples of competition for resources, unfair and illogical resource professional/ employees. However analysing data from distribution and poor decisional structure. Our study context-specific samples can be a useful way of developing indicates that physicians have to perform unreasonable a systematic understanding of organisational behaviour illegitimate tasks on an everyday basis, perhaps as a re- [50]. This study focused on physicians in academic medi- sult of poor task distribution within the hospital and cine and we believe that our findings are relevant to work those unreasonable illegitimate tasks make it more diffi- environments and occupations that are similar in terms of cult for physicians to manage their work tasks efficiently unreasonable illegitimate tasks, role conflict and sickness Our findings suggest that work tasks other than clinical presenteeism. treatment, research teaching duties that are mandatory for academic physicians are a promising target for inter- Conclusion ventions aimed at reducing unreasonable illegitimate Unreasonable illegitimate tasks have only recently been task load. Further, consistent with earlier findings the recognised as a workplace stressor and so there has been current findings suggest that role conflict is related to relatively little systematic investigation of their effects and unreasonable illegitimate task load [7]. relationships with other variables [4]. This study contrib- This study is consistent with the hypothesis that health utes to the field by providing evidence on physicians’ is affected by unreasonable illegitimate tasks [4, 7, 10], experience of unreasonable illegitimate tasks. Overall, our as it provides evidence that unreasonable illegitimate findings provide support for the notion that unreasonable tasks predict sickness presenteeism amongst physicians illegitimate tasks should be recognised as a stressor in the when controlling for variance in age, gender, role con- field of occupational health psychology, we have identified flict, control over work pace, exhaustion, and adminis- correlates of unreasonable illegitimate tasks, including trative tasks. It is possible that physicians experience sickness presenteeism. Focusing on factors in the work en- unreasonable illegitimate tasks as a kind of attendance vironment should allow us to find ways of reducing Thun et al. BMC Health Services Research (2018) 18:407 Page 8 of 9 unreasonable illegitimate task loads. The study findings Author details Department of Research and Development, Division of Psychiatry, St. Olavs indicate that unreasonable illegitimate tasks may leads to Trondheim University Hospital, Trondheim, Norway. Regional Centre for potential negative work behaviour such as sickness pres- Health Care Development, St Olavs Trondheim University Hospital, enteeism. Although this study does not provide a compre- Trondheim, Norway. hensive picture of illegitimate tasks or detailed strategies Received: 22 December 2017 Accepted: 23 May 2018 for reducing the proportion of time spent on them, the findings suggest that it would be worth investigating the relationships between unreasonable illegitimate tasks and References work attendance and performance. We conclude that phy- 1. Semmer NK, Jacobshagen N, Meier LL, Elfering A. Occupational stress sicians spent a high proportion of their work time on un- research: the “stress-as-offense-to-self” perspective. 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A study of unreasonable illegitimate tasks, administrative tasks, and sickness presenteeism amongst Norwegian physicians: an everyday struggle?

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Abstract

Background: It has been shown that a recently defined stressor, ‘illegitimate tasks’, has negative effects on employees’ work motivation and health. Better understanding of the illegitimate tasks undertaken by physicians might contribute to a more resource-efficient division of labour within the health care system, with beneficial effects on organisational economics and employee performance. We aimed to investigate the prevalence of unreasonable illegitimate tasks, their associations with workplace variables and their impact on health, in particular sickness presenteeism. Methods: Cross-sectional data were collected in 2012. A sample of 545 Norwegian physicians answered an online questionnaire. The response rate was high (71.8%). The data were analysed using independent-samples t-tests, ANOVA and logistic regression. Results: About 50.2% of physicians in all clinical positions reported that at least 11% of their everyday tasks could have been done by other hospital personnel. Seven percent of the physicians reported that at least 31% of their daily workload consisted of unreasonable illegitimate tasks. There were no significant differences in unreasonable illegitimate tasks according to clinical position, age or gender. Administrative task load and role conflict were positively associated with unreasonable illegitimate tasks that physicians reported could be reallocated to non-medical professionals. Moreover, unreasonable illegitimate task was associated with a higher probability of sickness presenteeism after controlling for age, gender, role conflict, control over work pace, exhaustion and administrative tasks. Conclusions: The results confirm that physicians’ workload includes a high proportion of unreasonable illegitimate tasks and that this can contribute to sickness presenteeism. Investigation of work environmental factors can provide insight into the mechanisms behind unreasonable illegitimate tasks. Decreasing the amount of administrative tasks and role conflicts faced by physicians should be a priority. These findings could be used to make hospital task management more resource-efficient. Our results indicate that a substantial proportion of physicians’ work capacity could be re- allocated to core tasks. Further research is needed into the specific type and content of unreasonable illegitimate tasks undertaken by physicians in order to determine to whom they should be allocated to ensure a healthy and motivated workforce and provision of high quality, resource-efficient health care services. Keywords: Administrative tasks, Exhaustion, Physicians, Role conflict, Sickness Presenteeism, Unreasonable illegitimate tasks * Correspondence: lise.lovseth@ntnu.no Department of Research and Development, Division of Psychiatry, St. Olavs Trondheim University Hospital, Trondheim, Norway Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Thun et al. BMC Health Services Research (2018) 18:407 Page 2 of 9 Background them away from their core task, which is medical treat- It has been shown that a recently defined stressor related ment, whereas a hospital orderly would see the same task to improper use of work time, termed ‘illegitimate tasks’ as part of his or her daily work [4]. At the theoretical level [1, 2], is related to stress and well-being at work [3–7]. it has been argued that unreasonable and unnecessary Findings from both Europe and the US have been pub- illegitimate tasks should be treated as separate constructs lished [1, 4, 8, 9], but findings on illegitimate tasks and [8]. In this study we investigate reports of unreasonable their relationship with stress outcomes need to be vali- illegitimate tasks. Unreasonable illegitimate tasks are con- dated in samples from different cultures and occupational sidered the main facet of illegitimate task and deserve groups [1, 2, 10]. In addition, because organisations and research attention because of their association with work employees aim to minimise the frequency of illegitimate engagement and time pressure [14]. tasks, there is a need to explore possible antecedents of Physicians can be described as cost-generating profes- illegitimate tasks [4]. Efficiency has for many years been a sionals because they have high salaries and demand add- key policy goal in many Western countries [11]and itional treatment resources [15], so it is inefficient to increased knowledge about the extent and content of the have physicians carrying out tasks that could be per- illegitimate tasks undertaken by physicians would help to formed by others and it has been suggested that research improve the efficiency of health services. There is evidence into the medical profession’s experience of illegitimate that there has been an increase in the proportion of work tasks is needed [3]. Physicians’ perception of illegitimate time that physicians spend on non-core tasks [12], raising tasks can depend on a variety of factors within their concern that physicians’ time is not being used appropri- work context [16]. Ahmned, Eatough, and Ford [17] ately. This inappropriate use of physicians’ work time can found national variations in illegitimate task burden and be associated with performance of illegitimate tasks. To outcomes of undertaking illegitimate tasks. This study our knowledge there has not yet been any systematic investigated physicians at a Norwegian university hos- investigation of the proportion of physicians’ workload pital. As part of the public health care system, hospitals that is made up of unreasonable illegitimate tasks. The are owned by the government, run by regional health aim of this study was to investigate the prevalence of un- authorities and publicly funded as part of the national reasonable illegitimate tasks, associated psychosocial work budget. Part of hospitals’ income is activity-based, but environment factors and one health-related outcome physicians are permanent employees with fixed salaries. amongst physicians working in a hospital setting. General practitioners are self-employed, but publicly financed, partly on a fee-for-service basis. In addition Theoretical background Norway has a strong Work Environment Act and strong Illegitimate tasks, defined as work tasks that are not re- employment protection legislation. There is also a rela- lated to one’s core occupation or that one perceives as tively low power distance between employees and em- inappropriate and a waste of time, are an emerging issue ployers in Norway [18]. Power distance is the degree to in occupational stress research [2, 7]. If an employee which less powerful members of a society are comfort- perceives that a work task should have been carried it able with the unequal distribution of power and recog- out by others, or if it violates norms about expected nise it as legitimate [18]. In Norway, as in many other work tasks or challenges his or her professional identity countries, there has been a change in task management then it is considered illegitimate [1, 2]. The concept of il- and an increase in the amount of work time spent by em- legitimate tasks is derived from the stress-as-offense-to-self ployees on additional tasks and administration. Accord- (SOS) theoretical framework, which posits that being ingly, it is possible that illegitimate tasks are experienced assigned an illegitimate task may trigger stress reactions as a threat to time spent on core tasks. [1], based on Lazarus’s[13]assumptionthat stress isre- Health care workers, including physicians, report lated to threats to important goals. There are two types of spending increased amounts of time on meetings, illegitimate tasks: unnecessary and unreasonable [1, 2, 7]. administration, measurement and reporting rather than Unnecessary illegitimate tasks are defined as tasks that are working with patients [3, 12, 19]. The growing number perceived as a waste of time and need not be done by any- of administrative tasks diverts time and attention away one, and tasks that could have been avoided or carried out from more clinically important activities [19]. These ad- with less effort if things were organised more efficiently [2], ministrative tasks are not unnecessary, but are likely to e.g. transferring patient data manually because two techno- fall - to some extent - outside of the range of tasks phy- logical systems are incompatible. Unreasonable illegitimate sicians consider part of their professional role. Hence tasks are tasks that are outside one’s occupational role and there is a need to explore how administrative burden conflict with specific aspects of one’s role or occupational relates to reports of illegitimate tasks. A better under- status [2], e.g. physicians asked to transporting a bedbound standing of illegitimate tasks should make it possible to patient are likely to criticise the organisation for taking make better decisions about task assignment [7] and Thun et al. BMC Health Services Research (2018) 18:407 Page 3 of 9 task management. Ahmed et al. [17] highlighted the risk demands-resources model [33, 34] provides a theoret- that as a result of increased focus on the economic ical framework which explains why unreasonable growth, employees will find themselves assigned more illegitimate tasks may be associated with sickness present- tasks, including administrative tasks, that fall outside eeism. Unreasonable illegitimate tasks may be considered their formal job role. More knowledge of the correlates job demands, as it requires effort to carry them out and of illegitimate tasks should enable organisations to they impose demands on individuals who do so [7]. It is reduce their number [10] or find ways to manage them possible that in a bid to cope with the pressure of unrea- in a more resource-efficient manner. sonable illegitimate tasks, physicians use sickness presence As illegitimate tasks have been shown to act as a job as a strategy for coping with their high workload and so stressor it is important to investigate how they affect the relationship between unreasonable illegitimate tasks physicians’ health and well-being [4, 7, 20]. Previous and sickness presenteeism should be investigated [3]. research has shown that illegitimate tasks are negatively A high prevalence of tasks perceived as illegitimate can related to job satisfaction [4, 6] and positively related to imply that an organisation would benefit from allocating counterproductive behaviour [2] and stress reactions resources differently. As previous research on illegitimate among employees [21]. One study found that participants tasks has reported that they have consequences for both who experience a high burden of illegitimate tasks had individuals and organisations, there is a need for studies of higher levels of the stress hormone cortisol than peers the prevalence of illegitimate tasks in different professions dealing with fewer illegitimate tasks [22]. In addition, [2, 4, 7]. Although there have been advances in research illegitimate tasks have been shown to reduce sleep quality on illegitimate tasks studies of the relationships between [23], and have been prospectively associated with lower illegitimate tasks, workplace correlates and health-related mental health [5] as well as being correlated with negative outcomes are scarce [4, 9]. A job characteristic associated affect and low self-esteem at the end of the working day with illegitimate tasks, especially unreasonable illegitimate [8]. Illegitimate tasks have also been found to be strongly tasks, is role conflict, defined as lack of congruent expec- associated with strain outcomes, such as feelings of resent- tations and demands from other people in the workplace ment towards one’s organisation and irritability, over a [35, 36]. As the concepts of role conflict and illegitimate period of 2 months [7], and have been related to turnover tasks are highly related but distinguishable from each intention [10]. Overall, previous research indicates that other, it is important to control for role conflict in re- illegitimate tasks have negative consequences for both in- search on illegitimate tasks [1, 2, 7]. In addition, perform- dividuals and organisations, but none of these studies has ance of work tasks that are outside their core role or job looked at the experiences of physicians. We argue that in definition has been associated with stress and ill health in order to improve our understanding of unreasonable il- physicians [19, 37]. Investigating the relationship between legitimate tasks it is important to study the phenomenon unreasonable illegitimate tasks and health outcomes is im- in a specific profession, as illegitimate tasks are a specific, portant, as physicians’ ill health can indirectly or directly task-related stressor that constitutes a threat to one’s affect the quality of health care and patient safety [38–40]. professional identity [7, 9]. Based on the theoretical framework and review of pre- The SOS theoretical framework implies that being vious findings, the aim of this study was threefold: 1. To expected to undertake illegitimate tasks can increase the investigate what proportion of working time hospital risk of poor health amongst physicians. Performing il- physicians think they spend on unreasonable illegitimate legitimate tasks requires emotional and physical effort tasks and how this varies with clinical position, gender, and may induce symptoms of strain [7]. Cognitive, age and reported administrative workload. 2. To analyse affective and physical strain may result in exhaustion the relationship between unreasonable illegitimate tasks [24], and exhaustion has been shown to correlate with and reported administrative work amongst physicians illegitimate tasks [3, 7, 25]. Exhaustion has also been whilst controlling for variance in role conflict, gender shown to have a reciprocal relationship with sickness and age. 3. To describe the relationship between unrea- presenteeism [26], defined as attending work when ill sonable illegitimate tasks and sickness presenteeism in [27]. Amongst physicians strain and ill health often physicians after controlling for variance in age, gender, manifest as sickness presenteeism [28–30], which has been role conflict, control over work pace, exhaustion and shown to be prevalent among physicians [28, 30, 31]. Physi- administrative tasks. cians often go into work when they are ill, because of their high work load, the lack of a replacement, responsibility Method and their crucial role in hospitals’ main task, which is Participants and procedure medical treatment [28, 30, 32]. Illegitimate tasks can be The study is based on survey data from a sample of regarded as stressors that can contribute to strain and Norwegian university hospital physicians participating in a variety of negative health outcomes [21]. The job a study concerning work-related health, organisational Thun et al. BMC Health Services Research (2018) 18:407 Page 4 of 9 culture and working conditions amongst European phy- reference category. Age was captured using nine age sicians (HOUPE study, phase II). We conducted a categories: ≤ 29 years (1); 30–34 years (2); 35–39 years web-based survey, in English, between February and (3); 40–44 years (4); 45–49 years (5); 50–54 years (6); May 2012. Participants received a letter describing the 55–59 years (7); 60–64 years (8) ≥ 65 years (9). study and containing a link to the questionnaire; they provided their responses anonymously. The participants Administrative/management tasks were qualified physicians and in full- or part-time em- The respondents were asked to report the percentage of ployment at the time of data collection. The project was their work time that was taken up by management and approved by the hospital board, the union representa- administration tasks. tives of the physicians at the hospital and the Regional Ethics Board. As well as sending out an email giving Role conflict information about the project, the research team also Role conflict was measured using three items from the gave short, oral presentations to all departments and General Nordic Questionnaire for Psychological and clinics at appropriate meetings. Participation was volun- Social Factors at Work (QPS Nordic) [41]. The selected tary and the online survey could not be accessed until items deal with conflicts between demands and re- consent to participation had been provided. The re- sources, conflicting requests and conflicts between the sponse rate was 71.8% (N = 545/759). Just under half the subject’s expectations and external demands [42]. participants (45%, n = 245) were female physicians. An Example item: “How often do you receive incompatible analysis of non-respondents showed that the sample was requests from two or more people?” Responses were representative of all physicians of the hospital in terms given on a five-point scale ranging from “very seldom or of age, gender, and position. never” (1) to “very often or always” (5). Cronbach’s alpha for this scale (α = .68) corresponded to the validation Measures data on QPS Nordic [41, 42]. A high score indicates high The questionnaire included 123 items on education, role conflict. work-related health, organisational culture and working conditions. Here we report on the variables relevant to Control over work pace our objectives: illegitimate tasks, role conflict, control We measured control over work pace with four items over work pace, amount of administrative tasks, exhaus- from the QPS Nordic [42] dealing with control over tion and sickness presenteeism. work pace, decisions about the timing and length of breaks and decisions about working hours (flexitime). Unreasonable illegitimate tasks Responses were given on a five-point scale ranging from The proportion of physicians’ workload made up of “very seldom or never” (1) to “very often or always” (5). unreasonable illegitimate tasks was measured by the Cronbach’s alpha for the scale (α = .83) corresponded to item “In your opinion, what proportion of the tasks you the validation data on QPS Nordic. deal with every day could be done by other hospital personnel (non-physicians)?” The response options were: Exhaustion none (coded 1); 5–10% (2); 11–20% (3); 21–30% (4); Exhaustion was measured using five items from the ≥31% (5). The data from the ordinal variable were Oldenburg Burnout Inventory (OLBI) [24](α = .73). The recoded into a binary variable: low level of unreasonable measure included both positively and negatively worded illegitimate tasks (0 = 0–10%) and high level of unrea- items (revised). Example item: “After work I usually feel sonable illegitimate tasks (1 = ≥11%) to enable analysis of worn out and weary”. Responses were given using a mean differences in work environment factors on the four-point Likert scale ranging from “totally agree” (1) to basis of level of unreasonable illegitimate tasks. The “totally disagree” (4). High scores on the burnout mea- cut-off between low and high level of unreasonable illegit- sures indicate a feeling of exhaustion. imate tasks was based on Eatough et al.’s[9]findingsthat illegitimate tasks can occur several times within a work- Sickness presenteeism day, with an average of 2 and 3 such tasks per week. This was measured with two questions: “Have you gone to work with an illness in a situation where you would Personal characteristics have recommended a patient to stay at home?” followed Participants were asked to describe their current clinical up by “How often has this happened during the last 12 position using one of the following categories: resident months?” [29]. Responses were coded as follows: none doing specialist training (1), specialist/consultant/medical (1), once (2), 2–4 times (3) and > 5 times (4). Employees officer (2), chief physician/senior medicalofficer/director were classified as showing sickness presenteeism if they (3) or other (4). Gender was coded with male (1) as the had attended work whilst ill as least twice during the Thun et al. BMC Health Services Research (2018) 18:407 Page 5 of 9 previous 12 months [43]. The variable was dichotomised gender and age. The results from the logistic regression as regular attendance (0) and sickness presenteeism (1). are summarised in Table 3. There was a positive rela- tionship between unreasonable illegitimate tasks and Statistical analyses amount of administrative tasks (b = .03, p < .001). In The illegitimate tasks variable is reported as a percent- terms of interpreting the findings it is important to note age and frequency. One-way ANOVA was used to assess that administrative tasks are coded in terms of percent- differences in illegitimate task load on the basis of clin- age of working time meaning that the unstandardised ical position. Independent samples t-tests (two-tailed) coefficient reflects an increase of 1 %. Criteria set out by were used to assess mean differences between psycho- Cox and Snell and Nagelkerke [45] show that the logistic social strain variables in participants with low and high model explained between 10.4 and 13.9% of the variance loads of illegitimate tasks. Logistic regression models in illegitimate tasks. These findings indicate that physi- were used to describe correlates of illegitimate tasks and cians who have a high administrative task load and experi- illegitimate tasks as a correlate of sickness presenteeism. ence conflict are also likely to report a high unreasonable We confirmed that the data met the requirements for illegitimate task load. logistic regression analysis [44, 45]. SPSS version 24 was The analyses show that there were systematic differ- used for the analyses. ences in psychosocial variables based on unreasonable illegitimate task load. Participants with a high unreason- Results able illegitimate task load experienced greater role conflict Descriptive statistics (M =2.82, SD = 0.75) than participants with a low unrea- Table 1 presents means, standard deviations and correla- sonable illegitimate task load (M =2.44, SD =0.80, t tions between the variables. The bivariate correlations (534) = 5.62, p < 0.001). This was a medium effect indicated positive associations between unreasonable (Cohen’s d = 0.49). Sickness presenteeism was greater illegitimate tasks and role conflict (r = .20, p < 0.001), in participants with a high unreasonable illegitimate and sickness presenteeism (r = .12, p < 0.01). The variable task load (M = 2.61, SD = 0.85) than participants with a low most closely associated with unreasonable illegitimate unreasonable illegitimate task load (M =2.34, SD = 0.91, tasks was administrative workload (r = .23, p < 0.001). t (535) = 3.57, p < 0.001). This was a medium effect The variable most associated with sickness presenteeism (Cohen’s d = 0.31). These results show that a high un- was exhaustion (r = .27, p < 0.001). reasonable illegitimate task load is more stressful than The question of whether unreasonable illegitimate a low unreasonable illegitimate task load. tasks was prevalent amongst physicians was explored. Finally, we hypothesised that unreasonable illegitimate Table 2 shows that 50.2% physicians reported that at tasks would be related to sickness presenteeism after least 11% of their everyday tasks could have been done controlling for variance in age, gender, role conflict, con- by other hospital personnel. Approximately 7% of the trol over work pace, amount of administrative tasks, and physicians reported that at least 31% of their workload exhaustion. The results from the logistic regression are consisted of unreasonable illegitimate tasks. There were summarised in Table 4. They indicate that the unreason- no mean differences of unreasonable illegitimate tasks able illegitimate tasks variable was a positive predictor of according to clinical position, age or gender. Table 2 sickness presenteeism. The OR for unreasonable il- shows data on physicians’ unreasonable illegitimate tasks legitimate tasks was 1.69 (p < 0.01), indicating that, on among all physicians and based on their current clinical average, a physician who reports a high load of unrea- position. sonable illegitimate tasks had an OR for sickness pres- We also analysed the associations between unreason- enteeism of 1.69. Exhaustion had the highest OR value able illegitimate tasks and amount of administrative (OR =1.81, p < 0.001), indicating that as level of ex- tasks after controlling for variance in role conflict, haustion increases the probability of attending work Table 1 Means (M), Standard Deviations (SD), and Correlations between the study variables Measure M (SD) 123 4 56 1. Unreasonable illegitimate Work Task 2.66 (1.08) – 2. Administrative Task 20.27 (18.14) .23** – 3. Role Conflict 2.64 (0.80) .20** .06 – 4. Control over Work Pace 2.76 (0.94) .04 .15** −.20** – 5. Exhaustion 2.48 (0.60) .05 .04 .32** −28** – 6. Sickness Presenteeism 2.47 (0.89) .12* .03 .17** −24** .27** – *p < .01 **p < .001 Thun et al. BMC Health Services Research (2018) 18:407 Page 6 of 9 Table 2 Physicians’ unreasonable illegitimate task load as a Table 4 Predictors of sickness presenteeism among physicians percentage of task load (n = 538) Variable b Wald OR 95% CI for OR Unreasonable All Employees Residents Specialists Others Unreasonable illegitimate Tasks 0.53* 6.69 1.69 [1.14–2.52] illegitimate n (%) n (%) n (%) n (%) Role Conflict 0.08 0.33 1.08 [0.83–1.40] Work Tasks Control over Work Pace −0.44** 15.48 .64 [0.52–0.80] None 69 (12.6) 28 (13.5) 41 (14.2) 2 (4.8) Exhaustion 0.59** 11.24 1.81 [1.28–2.55] 5–10% 194 (35.5) 79 (38.2) 103 (35.6) 12 (28.6) Administrative Tasks 0.004 0.55 1.00 [0.99–1.02] 11–20% 166 (30.3) 65 (31.4) 85 (29.4) 16 (38.1) Gender 0.02 0.006 1.02 [0.69–1.50] 21–30% 71 (13.0) 21 (10.1) 42 (14.5) 8 (19.0) Age −0.07 0.93 [0.85–1.02] 31% or more 38 (6.9) 16 (7.7) 18 (6.2) 5 (11.9) -2log likelihood 619.37** Total n 538 (98.4) 207 289 42 Cox & Snell R .107 Nagelkerke R .144 Note. *p < .05, **p < .001 whilst sick also increases. The OR for control over work pace was 0.64 (p < 0.001), indicating that as control over work pace increases the probability of at- In more detail, this study showed that 50% of all physi- tending work whilst sick decreases. Criteria set out by cians reported that more than 10% of their daily task Cox and Snell and Nagelkerke [45] indicated that the load consisted of unreasonable illegitimate tasks, i.e. logistic model explained between 10.7 and 14.4% of tasks that could have been done by other hospital staff. the variance in sickness presenteeism. This finding is consistent with Aronsson and colleagues’ [3] suggestion that physicians spend time on tasks that Discussion are not part of their professional role. Our results indi- This study has shown that Norwegian hospital physicians cate that a substantial proportion of physicians’ work have a high unreasonable illegitimate task load, as 50.2% of capacity could be re-allocated to core tasks. On the basis the participants reported that at least 11% of their task load of our results we estimate that between 8 and 13% of consisted of unreasonable illegitimate tasks on a daily basis. daily physician resources could be re-allocated. It follows Approximately 7% of the physicians reported that at least that re-allocation would increase total use of resources, 31% of their daily work tasks were unreasonable illegitimate as employees in other roles would have to compensate tasks. Another main finding is that a high unreasonable for the loss of physician resources to ensure that these illegitimate task load was more stressful than a low unrea- tasks continue to be performed effectively, but since sonable illegitimate task load. Participants with a high physicians can be regarded as a scarce resource, redu- unreasonable illegitimate task load reported a higher pro- cing the time they spend on illegitimate tasks should be portion of administrative tasks and more role conflict than considered a more efficient allocation of resources. participants with a low unreasonable illegitimate task load. It seems likely that the tasks physicians define as unrea- In addition, participants with a high unreasonable illegitim- sonable and illegitimate are tasks outside their field of ex- ate task load were more likely to attend work whilst sick pertise and therefore more appropriate to other (health) than colleagues with low unreasonable illegitimate task personnel. For instance, re-allocating administration of loads. Moreover, the findings indicate that unreasonable il- intra-vitreal injections from physicians to nurses was legitimate tasks and exhaustion both increase the likelihood shown to be a resource-efficient usage of personnel that of sickness presenteeism among physicians, whereas a high enabled hospitals to cope with an increase in physicians’ control over work pace appears to decrease the odds of workload. DaCosta and colleagues [46]together with physicians attending work whilst sick. Michelotti and colleagues [47] suggested that skill mix (changing professional roles) [48] is beneficial, acceptable Table 3 Predictors of unreasonable illegitimate tasks amongst to patients, and an effective use of resources. The effect- physicians iveness of skill mix across professions remains relatively Variable b Wald OR 95% CI for OR unexplored [49] and the likely consequences of skill mix Administrative Tasks 0.03* 21.41 1.03 [1.02–1.04] change need to be explored [48]. It is important that fu- Role Conflict 0.64* 25.40 1.77 [1.48–2.43] ture research should investigate the extent to which skill mix can reduce illegitimate task loads (in a hospital con- Gender −0.80 0.15 0.92 [0.63–1.36] text) or contribute to more efficient use of staff resources. Age −0.06 1.28 0.95 [0.86–1.04] At the same time, future research should identify which -2log likelihood 630.21* work tasks physicians consider illegitimate and why,as Cox & Snell’s R .104 Nagelkerke’s R .139 well as exploring how such tasks could be made attractive Note. *p < .001 to physicians or other health professionals. Thun et al. BMC Health Services Research (2018) 18:407 Page 7 of 9 At this point it is important to consider whether the pressure that contributes to a conflict between looking tasks that physicians perceive as illegitimate for a phys- after one’s own health and caring for one’s patients. Phy- ician really are. For instance, in many professions admin- sicians may feel under pressure to attend work when istrative tasks are increasingly a part of the job they are ill because it is patients who suffer when they description [12]. Administrative tasks might be perceived spend time on unreasonable illegitimate tasks or are ab- by physicians as illegitimate because they are not directly sent because of sickness. Another explanation is that related to clinical treatment. We found a positive associ- physicians attend work whilst ill in order to compensate ation between high amount of administrative tasks and for high workload [3]. In the long run compensatory unreasonable illegitimate task load amongst physicians sickness presenteeism can be counterproductive and after controlling for variance in role conflict. One poten- should be avoided, as it could damage the individual, tial approach to reducing physicians’ perceived amount colleges and the organisation [3]. Physicians are known of unreasonable illegitimate tasks would be to focus on to have high rates of sickness presenteeism [28–30], and their administrative workload or provide them with the our findings suggest that the risk of physicians attending tools they need to manage these tasks more efficiently work whilst sick could be reduced by reducing their un- [19]. As previous research has shown that a high admin- reasonable illegitimate task load and level of exhaustion istrative burden causes negative affect and prevents phy- or increasing their control over their work pace. sicians from putting patients first [12], it is important to address and adjust administrative tasks that are per- Limitations ceived as unreasonable and illegitimate. According to Although the results provide support for the study hy- the SOS theoretical framework, expecting employees to potheses the cross-sectional design means that we cannot perform illegitimate tasks is an active violation of the make causal inferences. However, as previous studies have psychological contract between employer and employee, indicated that illegitimate tasks predict strain, it is plaus- as illegitimate tasks disturb norms and rules associated ible to suggest that unreasonable illegitimate tasks trigger with a profession [1, 4, 7]. Illegitimate tasks threaten sickness presenteeism rather than the other way around. professional identity and are therefore particularly The consequences of illegitimate tasks should be investi- stressful [7]. Thus, being subjected to a high administra- gated through longitudinal research. Common method tive work load and role conflict may make physicians variance is a potential problem for our study because all more likely to perceive tasks as illegitimate, because the variables were self-reported. But self-reports are prob- such tasks fall outside their contracted work or profes- ably the most appropriate source of data on illegitimate sional role. Björk and colleagues [4] found that the fol- tasks as the judgement about legitimacy is a matter of lowing organisational variables were positively associated individual perception and experience [25]. Generalisability with managers’ reports of illegitimate task load: internal is also an issue, as studies often have single samples of competition for resources, unfair and illogical resource professional/ employees. However analysing data from distribution and poor decisional structure. Our study context-specific samples can be a useful way of developing indicates that physicians have to perform unreasonable a systematic understanding of organisational behaviour illegitimate tasks on an everyday basis, perhaps as a re- [50]. This study focused on physicians in academic medi- sult of poor task distribution within the hospital and cine and we believe that our findings are relevant to work those unreasonable illegitimate tasks make it more diffi- environments and occupations that are similar in terms of cult for physicians to manage their work tasks efficiently unreasonable illegitimate tasks, role conflict and sickness Our findings suggest that work tasks other than clinical presenteeism. treatment, research teaching duties that are mandatory for academic physicians are a promising target for inter- Conclusion ventions aimed at reducing unreasonable illegitimate Unreasonable illegitimate tasks have only recently been task load. Further, consistent with earlier findings the recognised as a workplace stressor and so there has been current findings suggest that role conflict is related to relatively little systematic investigation of their effects and unreasonable illegitimate task load [7]. relationships with other variables [4]. This study contrib- This study is consistent with the hypothesis that health utes to the field by providing evidence on physicians’ is affected by unreasonable illegitimate tasks [4, 7, 10], experience of unreasonable illegitimate tasks. Overall, our as it provides evidence that unreasonable illegitimate findings provide support for the notion that unreasonable tasks predict sickness presenteeism amongst physicians illegitimate tasks should be recognised as a stressor in the when controlling for variance in age, gender, role con- field of occupational health psychology, we have identified flict, control over work pace, exhaustion, and adminis- correlates of unreasonable illegitimate tasks, including trative tasks. It is possible that physicians experience sickness presenteeism. Focusing on factors in the work en- unreasonable illegitimate tasks as a kind of attendance vironment should allow us to find ways of reducing Thun et al. BMC Health Services Research (2018) 18:407 Page 8 of 9 unreasonable illegitimate task loads. The study findings Author details Department of Research and Development, Division of Psychiatry, St. Olavs indicate that unreasonable illegitimate tasks may leads to Trondheim University Hospital, Trondheim, Norway. Regional Centre for potential negative work behaviour such as sickness pres- Health Care Development, St Olavs Trondheim University Hospital, enteeism. Although this study does not provide a compre- Trondheim, Norway. hensive picture of illegitimate tasks or detailed strategies Received: 22 December 2017 Accepted: 23 May 2018 for reducing the proportion of time spent on them, the findings suggest that it would be worth investigating the relationships between unreasonable illegitimate tasks and References work attendance and performance. We conclude that phy- 1. Semmer NK, Jacobshagen N, Meier LL, Elfering A. Occupational stress sicians spent a high proportion of their work time on un- research: the “stress-as-offense-to-self” perspective. 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BMC Health Services ResearchSpringer Journals

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