Work Stress in the Nursing Profession

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1 Sayyed Mohammad Haybatollahi Work Stress in the Nursing Profession An Evaluation of Organizational Causal Attribution

2 II Social psychological studies 20 Publisher: Department of Social Psychology, University of Helsinki Editorial Board: Klaus Helkama, chairperson Inga Jasinskaja-Lahti, managing editor Karmela Libkind Anna-Maija Pirttilä-Backman Kari Mikko Vesala Maaret Wager Jukka Lipponen Copyright: Sayyed Mohammad Haybatollahi and Department of Social Psychology University of Helsinki P.O. Box 4 FIN University of Helsinki ISBN (Print) ISBN (PDF) ISSN Cover design: Mari Soini Helsinki, Yliopistopaino, 2009

3 III ABSTRACT The goal of this study was to examine the role of organizational causal attribution in understanding the relation of work stressors (workrole overload, excessive role responsibility, and unpleasant physical environment) and personal resources (social support and cognitive coping) to such organizational-attitudinal outcomes as work engagement, turnover intention, and organizational identification. In some analyses, cognitive coping was also treated as an organizational outcome. Causal attribution was conceptualized in terms of four dimensions: internalityexternality, attributing the cause of one s successes and failures to oneself, as opposed to external factors, stability (thinking that the cause of one s successes and failures is stable over time), globality (perceiving the cause to be operative on many areas of one s life), and controllability (believing that one can control the causes of one s successes and failures). Several hypotheses were derived from Karasek s (1989) Job Demands Control (JD-C) model and from the Job Demands Resources (JD-R) model (Demerouti, Bakker, Nachreiner & Schaufeli, 2001). Based on the JD-C model, a number of moderation effects were predicted, stating that the strength of the association of work stressors with the outcome variables (e.g. turnover intentions) varies as a function of the causal attribution; for example, unpleasant work environment is more strongly associated with turnover intention among those with an external locus of causality than among those with an internal locuse of causality. From the JD-R model, a number of hypotheses on the mediation model were derived. They were based on two processes posited by the model: an energy-draining process in which work stressors along with a mediating effect of causal attribution for failures deplete the nurses energy, leading to turnover intention, and a motivational process in which personal resources along with a mediating effect of causal attribution for successes foster the nurses engagement in their work,

4 IV leading to higher organizational identification and to decreased intention to leave the nursing job. For instance, it was expected that the relationship between work stressors and turnover intention could be explained (mediated) by a tendency to attribute one s work failures to stable causes. The data were collected from among Finnish hospital nurses using e- questionnaires. Overall 934 nurses responded the questionnaires. Work stressors and personal resources were measured by five scales derived from the Occupational Stress Inventory-Revised (Osipow, 1998). Causal attribution was measured using the Occupational Attributional Style Questionnaire (Furnham, 2004). Work engagement was assessed through the Utrecht Work Engagement Scale (Schaufeli & al., 2002), turnover intention by the Van Veldhoven & Meijman (1994) scale, and organizational identification by the Mael & Ashforth (1992) measure. The results provided support for the function of causal attribution in the overall work stress process. Findings related to the moderation model can be divided into three main findings. First, external locus of causality along with job level moderated the relationship between work overload and cognitive coping. Hence, this interaction was evidenced only among nurses in non-supervisory positions. Second, external locus of causality and job level together moderated the relationship between physical environment and turnover intention. An opposite pattern of interaction was found for this interaction: among nurses, externality exacerbated the effect of perceived unpleasantness of the physical environment on turnover intention, whereas among supervisors internality produced the same effect. Third, job level also disclosed a moderation effect for controllability attribution over the relationship between physical environment and cognitive coping. Findings related to the mediation model for the energetic process indicated that the partial model in which work stressors have also a direct effect on turnover intention fitted the data better. In the mediation model for the motivational process, an intermediate mediation effect in which the effects of personal resources on turnover intention went through two mediators (e.g., causal dimensions and organizational identification) fitted the data better. All dimensions of causal attribution appeared to follow a somewhat unique pattern of mediation effect not only for energetic but also for motivational processes. Overall findings on

5 V mediation models partly supported the two simultaneous underlying processes proposed by the JD-R model. While in the energetic process the dimension of externality mediated the relationship between stressors and turnover partially, all the dimensions of causal attribution appeared to entail significant mediator effects in the motivational process. The general findings supported the moderation effect and the mediation effect of causal attribution in the work stress process. The study contributes to several research traditions, including the interaction approach, the JD-C, and the JD-R models. However, many potential functions of organizational causal attribution are yet to be evaluated by relevant academic and organizational research. Keywords: organizational causal attribution, optimistic / pessimistic attributional style, work stressors, organisational stress process, stressors in nursing profession, hospital nursing, JD-R model, personal resources, turnover intention, work engagement, organizational identification.

6 VI ACKNOWLEDGEMENTS Without a network of support consisting of various people and instititutions, it would have been impossible to accomplish this study. Firstly, I am indebted to those Finnish hospital nurses who benevolently sacrificed their time and thoughts to this study by responding to a relatively long questionnaire. I am also deeply thankful to the managers of the Finnish Hospital Nurses Union (Sairaanhoitajaliitto) who provided me with the addresses of Finnish hospital nurses and allowed to run the data collection under the credit of the Union. I am deeply grateful to my supervisor Professor Klaus Helkama. His unconditional support and the time he provided were essential in resolving all the problems I encountered. I am also thankful to my second supervisor Professor Jukka Lipponen for his encouragement, guidance, and inspiring discussions. I am honored to have had the opportunity to work with such wonderful scholars. I also thank Professor Anna-Maija Pirttilä-Backman, the head of the Department of Social Psychology for her wonderful post-graduate seminars as well as for providing resources and facilities for this study. I would like to address my sincere thanks to the evaluators of the study, Professor Ulla Kinnunen and Dr. Jari Hakanen, whose comments led to uncover more on the potential of the study. I am also grateful to Professor Lauri Tarkkonen and his seminar on statistics and methodology for inspiring comments on the very first stages of this study. I would also like to acknowledge those friends and colleagues in the Department of Social Psychology who helped bring this study to fruition. Many thanks go to Päivi Berg for her guidance on my financial questions and for her unconditional help on checking and retranslating some parts of the questionnaire. To Erling Solhime go thanks for his wonderful

7 VII comments during two courses on advanced statistics. Special thanks go to Dr. Simo Määttä for a thorough editing review and language check. Finally, my special thanks go to my family: to my wife, Armaghan, for her encouragements and providing enough space for me to accomplish my PhD by taking most of the parenting responsibilities of our children; to my beloved brothers and sisters for their wonderful support during my study when I fell apart from my motherland, Iran; and to my precious children Amin and Yasamin for being my most valuable resource throughout this study. During my doctoral study I have been financially supported by the Iranian Ministry of Sciences, Research and Technology, by a grant from the Finnish Work Environment Fund, and by a grant from the University of Helsinki, for which I am deeply indebted. Sayyed Mohammad Haybatollahi July 2009, Helsinki

8 VIII CONTENTS 1 INTRODUCTION Work stress Causal attribution The gaps in existing literature Objectives and the research questions LITERATURE REVIEW Stress and different approaches Work stressors in the nursing profession Intrinsic job characteristics Organizational role stressors Reactions to work stressors Strain Organizational-attitudinal reactions to stressors Moderators of work stressors stress reactions Personality dispositions Situational variables Social support Mediators of the work stress process Models of the work stress process The attributional style construct Background and origin Organizational attributional style Evaluation of the measures Causal explanations: some measurement issues Causal dimensions: some measurement issues The Occupational Attributional Style Questionnaire (OASQ) Implications of attribution theory in stress research... 58

9 Attributions and the transactional approach to the work stress process Subjective versus objective: a different perspective Summary THE PRESENT STUDY: MODELS AND HYPOTHESES Building theoretical links Direct relationships The moderation model Control-related dimensions of attribution as the first moderators Job level as the second moderator Individual-organizational reactions to stressors The mediation model RESEARCH METHODOLOGY Methods and Data Sample Procedure Response statistics Variables and measures Work stressors Personal resources Causal dimensions of attribution Optimistic/pessimistic organizational attributional style Organizational identification Work engagement Turnover intention Control variables Statistical analysis RESULTS Preliminary data analysis Screening the data Pre-analysis Descriptive statistics, scale reliability, and zero order correlations Direct associations IX

10 X Turnover intention as dependent variable Work engagement as dependent variable Organizational identification as dependent variable Cognitive coping as dependent variable Optimistic occupational attributional style Pessimistic occupational attributional style Moderation models Testing the hypotheses Building a mediation model Locus of causality Testing the Hypotheses Stability Testing the Hypotheses Globality Testing the Hypotheses Controllability Testing the Hypotheses Summary of testing the hypotheses DISCUSSION The main findings and their contributions to the literature Direct effects Moderating effects Mediating effects of causal dimensions Work stressors and the energy draining process Personal resources and the motivational process Causal Steps Limitations of the study The implications of the results Theoretical implications Practical implications Directions for future research REFERENCES APPENDICES...230

11 XI TABLES & FIGURES Table 4.1. Respondents demographic statistics 87 Table 5.1. The results of the square root transformation. 104 Table 5.2. The t-test of different means between nurses in supervisory and non-supervisory positions over all the variables in the models. 105 Table 5.3. Descriptive statistics and scale reliabilities Table 5.4. Zero-order correlations between all the variables included the study Table 5.5. Hierarchical regression of the association of work stressors with the outcome variables 112 Table 5.6. Hierarchical regression results for the association of optimistic OAS with turnover intention, work engagement, and organizational identification 116 Table 5.7. Hierarchical regression results for the association of pessimistic OAS with turnover intention, work engagement, and organizational identification 117 Table 5.8. Hierarchical regression analysis for the three-way interaction of work overload, locus of causality and job level on turnover intention and cognitive coping Table 5.9. The results of the simple slope analysis and the t-test for the four combinations of external locus of causality and job level Table Hierarchical regression analysis for the three-way interaction of work overload, controllability attribution, and job level on turnover intention and cognitive coping 126 Table Hierarchical regression analysis for the three-way interaction of responsibility, external locus of causality, and job level on turnover intention and cognitive coping Table The results of the simple slope analysis and the t-test for the two combinations of responsibility and job level 130

12 XII Table Hierarchical regression analysis for the three-way interaction of responsibility, controllability attribution and job level on turnover intention and cognitive coping 131 Table Hierarchical regression analysis for the three-way interaction of physical environment, locus of causality, and job level on turnover intention and cognitive coping 133 Table The results of simple slope analysis and t-test for the four combinations of locus of causality and job level Table Hierarchical regression analysis for the three-way interaction of physical environment, controllability attribution, and job level on turnover intention and cognitive coping 138 Table The results of simple slope analysis and t-test for the four combinations of controllability and job level Table Fit indices of the structural equation model for the controllability model. 148 Table Bootstrap estimate and confidence interval for locus of causality. 151 Table Fit indices of the structural equation model for the stability model 156 Table Bootstrap estimate and confidence interval for stability.159 Table Fit indices of the structural equation model for the globality model Table Bootstrap estimate and confidence interval for globality Table Fit indices of the structural equation model for the controllability model 170 Table Bootstrap estimate and confidence interval for controllability 172 Table Summary of testing the hypotheses Figure 2.1. Simple moderation model of work stress 28 Figure 2.2. General framework linking personality to exposure and reactivity to stressors. 29 Figure 2.3. Karasek s Job Demands Control Model 32

13 XIII Figure 2.4. Kahn and Byosiere s (1992) theoretical framework of organizational Stress.. 45 Figure 2.5. Historical influences in the study of Attribution.. 47 Figure 3.1. Theoretical framework of the stressors personal resources dual processes with a mediated moderation role of causal dimensions of attribution 64 Figure 3.2. The hypothesized moderation roles of OAS and job level in the stress process 69 Figure 3.3. The hypothesized model of the mediation role of locus of causality in the proposed stress-resource model 78 Figure 3.4. The hypothesized model of the mediation role of the stability dimension attribution in the proposed stress-resource model 80 Figure 3.5. The hypothesized model of the mediation role of the globality dimension of attribution in the proposed stress-resource model.. 81 Figure 3.6. The hypothesized model of the mediation role of the controllability dimension of attribution in the proposed stress-resources model.. 82 Figure 4.1. Optimistic pattern of OAS for work-related success and failure. 96 Figure 4.2. Pessimistic pattern of OAS for work-related success and failure. 97 Figure 5.1. The three-way interaction effect of work overload, external locus of causality, and job level predicting cognitive coping among supervisors and non-supervisor nurses..123 Figure 5.2. The interaction effect of work overload and externality on cognitive coping 125 Figure 5.3. The two-way interaction effect of responsibility and job level predicting cognitive coping among supervisors and non-supervisor nurses Figure 5.4. The three-way interaction effect of physical environment, external locus of causality, and job level predicting turnover intention among supervisors and non-supervisor nurses. 135 Figure 5.5. The interaction effect of physical environment, externality, and job level on turnover intention 136

14 XIV Figure 5.6. The three-way interaction effect of physical environment, controllability attribution, and job level predicting cognitive coping among supervisors and non-supervisor nurses Figure 5.7. The interaction effect of physical environment and externality on cognitive coping. 142 Figure A uni-mediating model of testing the mediation effects of causal dimensions Figure A mediation model with two intermediate mediators for personal resources and turnover intention. 145 Figure 5.9. Hypothetical model for the mediating effects of internal and external locus of causality Figure Final model for the mediating effects of the dimensions of locus of causality Figure Hypothesized model for the mediating effects of the stability dimension 155 Figure The final model for the mediating effects of the stability dimension Figure Hypothesized model for the mediating effects of the stability dimension 162 Figure Final model for the mediating effects of the globality dimension Figure Full mediation model for the effects of the controllability dimension Figure Final mediation model for the effects of the controllability dimension..173 Figure Alternative final mediation model for the effects of the controllability dimension Figure 6.1. The process of energy draining with the partial effect of externality Figure 6.2. The motivational process with the mediation effect of the dimensions of causal attribution 195 Figure 6.3. The motivational process with the mediation effect of work engagement and organizational identification

15 1 INTRODUCTION It has been said: The whole is more than the sum of its parts. It is more correct to say that the whole is something else than the sum of its parts, because summing up is a meaningless procedure, whereas the whole-part relationship is meaningful. Kurt Koffka, 1935, p 176. Over the last century, stress as an interdisciplinary concept has become an area of great interest and has been researched extensively. Although the earliest studies on stress were mostly physiological, psychological models of stress have been developed once Selye (1956) established a link between stressors and illness in his model of general adaptation syndrome. The endeavor to understand psychological stress did not only involve the link between stress and illness; other human characteristics such as emotion, motivation, and performance were linked to stress. The realm of stress carries many diverse and distinct factors concerning the person and his or her environment. In organizational psychology, for example, stress is understood as a long-lasting and harmful emotional and somatic response to stressors when the requirements of work do not accord with employees capabilities, expectations, and needs. The reciprocal relationship between work stressors and the individuals cognitive mechanisms has long been considered as an important indicator to understand why different people appraise a situation as stressful or benign (see Lazarus, 1966). People make different types of cognitive appraisal for their perceived environmental threats. They also give reasons to positive and negative outcomes of their

16 2 actions as well as the actions of others. Causal attribution as a cognitive process of reasoning helps people to reduce the complexity of their environment. A sustained cognitive reasoning in people over their role in producing the outcomes normally does this. In addition, causal attribution helps researchers to get a clearer picture on why some people perceive outcomes of an action to be threatening but others do not. For several decades, researchers have devoted considerable effort to investigate the dimensions of causal attributions and their cognitive, emotional, and behavioral outcomes. Unfortunately, less work has focused on investigating the relationship between the components of the work stress process and causal attribution, assumed to represent a superior explanation in appraising work stressors Work stress According to the European Agency for Safety and Health at Work (2005), work stress is the second most prevalent work-related health problem after backache, affecting 22 percent of workers in 27 European countries. In addition, there is a strong business case. For instance, the annual economic cost of work-related stress in 15 European countries was estimated at 20 billion Euros in These statistics also indicated that more work needs to be done in all respects to reduce or control the consequences of work stress for individuals, society, and organizations. First of all, more academic studies on stress and related issues are needed. Work stress particularly in the nursing profession has become a major problem in recent years: hospital nurses have been reported to be exposed to a high level of work stressors (Petterson, et al., 1995). Studies have revealed that nurses are under the greatest work stress and the highest physical and psychological strain among other health care professionals (Rees & Cooper, 1992; Petterson, et al., 1995). In addition, work stress in the nursing profession appears to be associated with low job satisfaction (Healy & McKay, 1999, 2000; Demerouti et al., 2000) and a high rate of turnover and absenteeism (Borda & Norman, 1997). The nursing profession, particularly in the hospital setting, contains various job stressors: it requires highly demanding skills such as

17 teamwork in different situations, responsibility for the patients, and shift work (Meyer & Allen, 1997). While these work characteristics are potential stressors in the nursing profession, role overload, responsibility for colleagues and patients, and physical environment have been reported as the most challenging stressors for this profession. A review of the work stress literature indicates no lack of models to explain how individuals are subject to stress. However, despite a great body of findings and several models created to advance the current understanding of the nature of stress, there has always been a lack of a clear consensus over the definition of stress and its assessment. For example, stress has often been defined both as a dependent and as an independent variable; it has been defined also as a process (Cox, 1985). While some studies treat stress as a stimulus, others tend to refer to it as a response. For this reason, stress research is still dealing with difficulties and contradictions regarding the way the term stress is used or evaluated. Today, empirical knowledge about stress as stimulus, response, and interaction is bursting and researchers tend to consider the nature of stress as interaction between person and environment. In this understanding, stress is not a variable but a process including stressors along with other antecedents and outcome variables (Cooper, Dewe & O Driscoll, 2001). A comprehensive study of the nature of the stress process can be traced in contemporary approaches such as the one in which Lazarus (1966) suggests stress to be a transaction between person and environment. According to this definition, stress is not located in the individual or even in the environment, it resides in the conjunction between these two (Lazarus & Folkman, 1984). On a conceptual level, it is convenient to adopt a transactional approach, emphasizing the nature of the stress process as a definition for work stress. From this standpoint, many empirical studies use different definitions, which lead each study to emphasize particular elements of the stress process. This is due to the fact that different studies on stress, ranging from studies on particular elements to the whole process, have considered a wide variety of factors, research questions, and methodologies. This variety of methods applied in stress research has largely influenced the definition of stress adopted. Current trends in work stress research tend to study stress as a process. Although there is no consensus over a particular stress process, 3

18 4 Kahn and Byosiere (1992) have identified three main stages to illustrate the nature of the work stress process: 1) the presence of a stressor or demand, 2) a set of evaluative appraisal processes, and 3) generating a response. The second stage, which is a cognitive process in itself, requires further investigation through relevant cognitive constructs including causal attribution. Most studies on work stress have considered these three stages in their theoretical frameworks of work stress and during the past few years various models have emerged. However, it seems that it is too early to reach a consensus on a unique process of work stress: some models appear to have more potential to convey the work stress process than others. The Job Demands Resources (JD-R) model (Demerouti et al., 2001) is one of the new attempts in stress research to remove some of the limitations of earlier models by integrating positive aspects of work into stress research. Nevertheless, contrary to Kahn and Byosiere s (1992) suggestion, the JD-R model seems to fail to integrate a cognitive process into the model. For this reason, in the present study, causal attribution is integrated into the JD-R model in order to test its mediation effect in the dual processes proposed by the model. This issue will be addressed comprehensively in Chapters Two and Three Causal attribution The concept of causal attribution is the result of decades of research in cognitive and social psychology and it is a relatively new concept in organizational psychology. This cognitive process of reasoning was first introduced by Heider (1958), upon which Weiner and colleagues (1971) developed a theoretical framework of achievement motivation that has become a major research paradigm of social psychology (Weiner, 1994). They identified some important factors affecting attributions for achievement, among which ability, effort, task difficulty, and luck are the most important. In addition, attributing the causes of events to certain work-induced factors, which has been addressed within the concept of causal attribution, is one of the fast growing research areas in organizational studies.

19 Subsequently, the application of attribution theory has prompted development in other areas of psychology, which in turn has added more concepts to attribution theory. For instance, Seligman and colleagues (1975) explored the concept of attributional style while utilizing attribution theories to solve certain practical problems in the generalization of the primary theory of learned helplessness to human subjects. While attributional style is a personality characteristic that is developed upon reasoning for the consequences and outcomes of people s actions in family, school, or at work, the literature on attributional style is almost exclusively clinical in its nature. Individuals vulnerable to depression supposedly differ from those who are not vulnerable as to the causal interpretations they constantly make for good and bad events in their lives. Abramson et al. (1978) argue that a depressive attributional style is characterized by a tendency to view adverse events as caused by three factors: 1) internal factors (in contrast to external factors, such as the environment or the actions of others), 2) factors that are stable (rather than unstable or temporary), and 3) factors that exert global influence across many domains in one s life (rather than specific or narrow influence in only a few situations). In this regard, it is assumed that depressive attributional style can affect the perception of environmental threats leading to higher level of perceived work stress, which suggests a moderating effect for attributional style. On the other hand, having been exposed to work stressors for a long period is assumed to form a depressive attributional style leading to negative organizational-attitudinal outcomes, which suggests a mediation effect for this variable. To sum up, despite considerable efforts to develop attributional theories in organizational behavior, the application of this theory in organizational issues appeared to be too complicated. The overall suggestion of studies in this area is to integrate the construct of causal attribution into a model or a bigger process. This would increase the probability of uncovering the full potential of attribution theory in explaining organizational variables. There are growing needs to discover the full potential of this theory to explain problems regarding the relationship between the individual and the organizational environment. 5

20 The gaps in existing literature Since the 1950s, as the psychological aspect of the stress phenomenon have become an area of interest, contradictory findings have surprised the researchers (e.g., Appley & Trumbull, 1986; Mason, 1975). Indeed, there is still a lack of consensus over the definition of stress as either a single phenomenon or a rubric for a group of phenomena. On the one hand, the results of the studies within which stress has been considered as a single phenomenon have varied, so that they have failed to form a reliable theory (Lazarus, 1966; Lazarus & Folkman, 1984). On the other hand, grouping diverse phenomena together has created too much to explain by a single theory, so that several models of stress have emerged. Some of these models, such as the Person-Environment Fit model (Van Harrison, 1978), have failed to explain organizational stress empirically (Eulberg, Weekley, & Bhagat, 1988). This may also be a great concern of many other models of work stress. In addition, contradictions over the conceptualization, measurement, and terminology have added more complications to research on work stress. Besides, in spite of the emphasis placed on the role of cognitive constructs such as appraisal in the stress process, a shortage of exploring the process of work stress cognitively seems to constitute a real gap in the existing literature. For example, in a meta-analytical study on organizational stress (Kahn & Byosiere, 1992), no cognitive appraisal or other cognitive elements of the stress process were examined or emphasized. From a cognitive perspective, the existence of stressors may be less important to individuals well-being than the way in which they appraise the levels of stress (Aldwin & Rovenson, 1987). The key factor underlying a determining role for cognitive dispositions in the stress process is that people appraise differently and, thus, react in divergent ways to the same level of work stress. For such situations, in terms of causal attribution, the way in which the individual gives reason to his or her failures seems to be a robust explanation. For example, attributing the causes of failures to internal, global, and stable factors mediates one s reaction to the failures, leading to the blocking of further effort (energy drained) and eventually to depression (see Meyer, 1980; Abramson et al., 1978). Taken together, the process proposed by the present study

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