Burnout processes in non-clinical health service encounters

Abstract

This study employs Bagozzi's (1992) reformulation of attitude theory (appraisal → emotional response → behavior), to examine the antecedents and outcomes of burnout in a healthcare environment where healthcare workers are engaged in the novel context of non-clinical health service encounters. The findings identify significant relationships between job demand stressors (role overload, role conflict, role ambiguity and interpersonal conflict), symptoms of burnout (emotional exhaustion and depersonalization), affective job outcomes (job satisfaction and organizational commitment) and behavioral job outcomes (service recovery performance and turnover intentions) and extend our understanding of these phenomena in the largely unexplored yet important context of non-clinical health service delivery. The major implication for hospital managers is to ensure that non-clinical healthcare workers have adequate information pertaining to their job-related duties and responsibilities since role ambiguity is the only characteristic of the non-clinical work environment that influences subsequent appraisal (depersonalization), emotional response (organizational commitment) and behavior (service recovery performance) in the conceptualization of appraisal → emotional response → behavior.

Introduction

As boundary spanners, frontline employees play a significant role in the service encounter for organizations striving to enhance both customer relationships and organizational effectiveness (Kwortnik and Thompson, 2009, Singh, 2000). Understanding factors that affect frontline employee performance is particularly evident in the healthcare sector since a prerequisite to improving service quality is a thorough understanding of service encounters (Brunton, 2009, Cohen and Golan, 2007, Ramsaran-Fowdar, 2008). Berry and Bendapudi (2007) call for service researchers to seize the opportunity to look closely at the healthcare environment for insights that can inform service management research and practice. The identification of this void highlights both the need and the impetus for novel research to be undertaken in the area.

As participants in health service encounters, patients can influence the quality of healthcare delivery simply by reporting on which aspects are more or less important (Tritter, 2009). This has led the World Health Organization (WHO) to acknowledge non-clinical health service delivery as being an important dimension of overall service delivery and quality of care (Campbell et al., 2000, Valentine et al., 2008, Wensing et al., 1998) and in turn, quality of care has been shown to influence the bottom-line performance of hospitals (Jiang et al., 2006). In addition, Masnick and McDonnell, 2010, Valentine et al., 2008 highlight the lack of empirical data in this area, and Taché and Hill-Sakurai (2010) note the lack of attention being paid to these “highly necessary, but largely unnoticed in the literature” (p.289) non-clinical healthcare workers in service delivery.

In their boundary-spanning role, non-clinical healthcare workers face many challenges. One such challenge is job burnout which is a syndrome characterized by emotional exhaustion, a tendency to depersonalize others and diminished perceptions of ability on the job (see Worley et al., 2008 for a review and meta-analysis). In healthcare, Demerouti et al. (2000) refer to a myriad of antecedents of job burnout including emotionally demanding patient contacts, lack of time to plan and prepare work, frequent interruptions, and responsibility in the absence of decision-making authority. Collectively these are known as job demand stressors and are defined as “those physical, psychological, social or organizational aspects of the job that require sustained physical and/or psychological (cognitive and emotional) effort” (Bakker et al., 2003, p. 344). The negative implications of burnout are often profound for both the individual frontline employee as well as for the organizational healthcare provider, and can involve substantial costs due to turnover, absenteeism, job dissatisfaction, lower organizational commitment and compromised job performance (Albion et al., 2008, Maslach et al., 2001).

A substantial literature exists in healthcare relevant to the burnout construct and its antecedents (Ekstedt and Fagerberg, 2005, Vahey et al., 2004), however this literature largely focuses on clinical service delivery (Bakker et al., 2005) and the influence of healthcare worker burnout in high-acuity inpatient settings (Halbesleben et al., 2008), where role ambiguity would appear to be a less influential hindrance job demand stressor in influencing nurse job burnout (Lee et al., 2003), rather than on frontline hospital staff engaged in more traditional (less clinical) service encounters.

In addition, when looking at outcomes of burnout in clinical healthcare settings, the focus has been on patient outcomes e.g., patient safety as a result of nurse burnout (Halbesleben et al., 2008), the physical and mental health of healthcare workers (Peterson et al., 2008) and nurse affective e.g., job satisfaction and organizational commitment, and behavioral job outcomes e.g., turnover intentions (Seery and Corrigall, 2009) but not on job performance as a behavioral outcome. Moreover, these affective and behavioral job outcomes have remained largely unexplored in a non-clinical health service delivery context.

The present study examines one facet of overall job performance — service recovery performance; a critical component of the service encounter (Zeithaml et al., 1996) and “a fertile wide-open research” [territory] “for marketing scientists to explore” (Parasuraman, 2006, p. 590). Service recovery entails doing things very right the second time (De Ruyter and Wetzels, 2000), and the actions that a service worker takes to respond to service failures (Bendall-Lyon and Powers, 2001, Bitner et al., 1990, Grönroos, 1990). The service recovery performance of clinical healthcare workers is a critical component in health service quality and a healthcare organization's reputation (Osborne, 1995). Given that non-clinical health service delivery is an important component of overall quality of care and quality of service delivery, there is a need to examine burnout and service recovery performance of non-clinical healthcare workers.

Against this background, the present study examines the impact of relevant job demand stressors on the burnout process and the subsequent impact of burnout on specific affective and behavioral job outcomes. This is achievable by looking at non-clinical healthcare workers in a hospital setting where the service encounters are of a more typical nature and are not simply restricted to doctor–patient or nurse–patient clinical interactions. The study utilizes Bagozzi's (1992) reformulation of attitude theory which advocates self-regulating processes embodied as distinct sequences of monitoring and evaluation, emotional reactions and coping responses that govern behavior, rather than as attitudes and subjective norms that influence intentions and subsequent behavior. Bagozzi's (1992) theory provides a viable framework for a study of the burnout process, yet only a few studies in the past have used it in substantive contexts (Babakus et al., 2003 in the context of retail banking and Schmit and Allscheid, 1995 in security systems sales) — none of which are in a healthcare setting.

The organization of the paper follows. The next section presents the research framework used to guide the study and the hypotheses followed by a discussion of methodology and findings. The paper concludes with implications for service researchers and practitioners operating in health service provision and delivery, study limitations and opportunities for future research.