Red Tape and Voice in Dutch Healthcare: The Impact of Voice on Red Tape towards Job Stress and Job Satisfaction.
Frederieke de Bruin (s1765655) University of Groningen
Department of Human Resource Management and Organizational Behavior Nettelbosje 2, 9747 AE Groningen, The Netherlands
E-mail: f.c.de.bruin@student.rug.nl
Author Note
The present paper is my master’s thesis and is written under the supervision of L. Maxim Laurijssen. Correspondence concerning this thesis should be addressed to Frederieke de
Bruin, f.c.de.bruin@student.rug.nl
Abstract
Healthcare professionals encounter an abundance of rules and regulations in their job.
The present research argues and shows that healthcare professionals perceive this abundance as red tape, which is associated with increased job stress and reduced job satisfaction. More importantly, it is argued that voice may shield healthcare professionals against the negative effects associated with red tape. A questionnaire was distributed among 207 Dutch healthcare professionals. In line with expectations, red tape was positively associated with job stress and negatively with job satisfaction. Further, voice moderated these effects such that healthcare professionals experienced red tape less negatively when voice was high. That is, providing healthcare professionals with more voice may offset the potential negative effects of the plethora of rules that healthcare professionals experience.
Keywords: Healthcare professionals, red tape, job satisfaction, job stress, voice
Red Tape and Voice in Dutch Healthcare: The Impact of Voice on Red Tape towards Job Stress and Job Satisfaction.
The lingering changes to the ways in which healthcare is delivered have led to an abundance of rules and regulations which, in turn, have led to more demanding workloads for healthcare professionals (Duffield, & O’Brien-Pallas, 2003; Holland, Allen, & Cooper, 2013). Coincidentally, increased job stress and reduced job satisfaction is becoming a common occurrence among healthcare professionals (Hayes, O’Brien-Pallas, Duffield, Shamian, Buchan, Hughes, Laschinger, & North, 2012; Winstanley, & Whittington, 2002).
Interestingly, the Medical Economics even enlisted administrative burdens (red tape) and staff retention (job satisfaction and job stress) on rank 7 and 14 in their “Top 15 Challenges facing physicians in 2015”. The present research argues that healthcare professionals perceive the abundance of rules and regulations as red tape, which may account for their experiences of increased job stress and reduced job satisfaction.
Indeed, red tape is found to have negative effects on an organization’s outcomes and their employees (Feeney, 2012; Pandey, Coursey, & Moynihan, 2007; Pandey, & Kingsley, 2000; Scott, & Pandey, 2005). For instance, employees report that red tape prevents them to properly execute their job due to lack of flexibility (Pandey et al., 2007). Red tape is further associated with frustration and negative work attitudes overall (DeHart-Davies, & Pandey, 2005). Moreover, previous findings seem to suggest that new rules may be associated with increased negative work attitudes such as feelings of powerlessness, meaninglessness or frustration and the experience of suppressed responsibility or impeded personal growth (Buchanan, 1975; DeHart-Davies, & Pandey, 2005). This seems to suggest that red tape could also negatively affect job satisfaction and positively affect job stress.
As red tape may affect healthcare professionals negatively, it seems vital to
disentangle how these negative effects may be mitigated. Red tape is the result of
organizational processes as well as organizational decision making and both are found to impact employees’ job stress and job satisfaction (Cai, 2014; Lui, Batram, Casimir, &
Leggat, 2015). This seems to suggest that giving healthcare professionals a say – or voice – in the organizational decision making process may lower their negative valuation of red tape.
For instance, Turaga and Bozeman (2005) argued that the experience of red tape is lower when employees are given more voice. Therefore, the present research focuses on the moderating role of voice in the link between red tape and increased job stress and decreased job satisfaction, such that it is expected that high voice mitigates the potential positive link between red tape and job stress, and the negative link with job satisfaction.
All in all, this research aims to disentangle how healthcare professionals’ experience of the abundance of rules and regulations is related to their perceptions of job stress and job satisfaction and investigates whether and how voice moderates this relationship. One important practical implication of this research is a first attempt to find a way to shield healthcare professionals against the potential negative effects of red tape and, as such, provide them with a better work environment. Moreover, the present research aims to contribute to the voice literature by disentangling whether voice can be used as a tool to optimize healthcare professional’s work experiences (Simon, 1997; Turaga, & Bozeman, 2005).
Red Tape
Although multiple definitions of red tape exist, the majority of research (cf. Feeney, 2012) relies on Bozeman’s (2000) definition, who defined red tape as “burdensome rules and procedures that have negative effects on the organization’s performance”. All
conceptualizations of red tape boil down to a direct negative or adverse relation between
organizational rules and procedures, and organizational performance (Feeney, 2012). Red
tape is also argued to negatively impact employees within an organization (c.f. Pandey, &
Kingsley, 2000). That is, although red tape is originally defined at the organization level, more recently scholars began to recognize that red tape may also directly influence individual employees. For instance, Moynihan and Pandey (2007) argue that red tape may frustrate employees in achieving their goals or intended outcomes.
Indeed, previous research shows that red tape is associated with a range of negative outcomes at the employee level, such as, feelings of powerlessness, meaninglessness, and frustration. (Bozeman, & Kingsley, 1998; Moon, & Bretschneider, 2002; Scott, & Pandey, 2005). This seems to suggest that red tape may also be negatively related to job stress.
Red Tape and Job Stress
Karasek’s ‘Job Demand Control Model’ (cf. Karasek, 1979) is among the most used frameworks that relates the health and well-being of people to characteristics of the
workplace (Pisanti, van der Droef, Maes, Ahlbom, & Theorell, 2011). This framework revolves around job stress as a primary negative consequence of work, and aims to measure and explain the degree of stress or unhappiness amongst employees (Giauque, Anderfuhren- Biget, & Varone, 2013; Karasek, Baker, Marxer, Ahlbom, & Theorell, 1981). Karasek (1979) defines job stress as ‘an internal state of the individual in reaction towards their work
environment’s demands and its’ decision making freedom’. That is, stress refers to the emotional state and/or psychological state resulting from a perceived threat to people’s well- being originating from environmental factors (Ganster, 2008; Wittchen, Krimmel, Kohler, &
Hertel, 2013).
A variety of work-related aspects may impact people’s well-being and may bring
about experiences of job stress. Environmental factors that are found to be related to job
stress include high work pressure, irregular working hours, the pressure to meet a deadline,
frustration regarding rules, procedures or team members and/or lack of control (McGrath,
1976; Schuler, 1980). These environmental factors or job demands are not always negative
by nature but they may become stressors when employees fail to or are frustrated to deal with them (Quratulain, & Khan, 2015).
Generally, organizational red tape is associated with a propensity to develop high levels of job stress over time (Giauque et al., 2013), which seems to suggest that this may also translate to healthcare professionals’ experience of individual red tape. Indeed, inadequate work rules and procedures are found to be great stressors for nurses
(Adriaenssens, De Gucht, Van Der Droef, & Maes, 2010; Walsh, Dolan, & Lewis, 1998) Interestingly, a previous study showed that 50% of the healthcare managers regularly experience high levels of work-related tension and stress (Buchanan, Parry, Gascoigne, &
Moore, 2013). This seems to suggest that healthcare professionals may encounter red tape and their experience of it is poitively related to their perceptions of job stress. As such, I expect that:
Hypothesis 1a: Individual red tape is positively related to job stress.
Red Tape and Job Satisfaction
In addition to job stress, red tape may also be negatively related to job satisfaction, which can be defined as the “pleasurable or positive emotional state resulting from the appraisal of one’s job or job experience” (Locke, 1976). This emotional state is argued and found to derive from the fit between a person’s needs or wants in their job and the extent to which those needs and wants are satisfied. (Price, 2001; Quratulain, & Khan, 2015).
Antecedents of job satisfaction include growth, flexibility, self-actualization, meaningfulness and contentment (Motowidlo, Packard, & Manning, 1986).
Previous findings showed that organizational red tape is related to work motivation as well as job satisfaction, and that organizational red tape is negatively associated with job satisfaction (Bozeman, & Kingsley, 1998; Moon, & Bretschneider, 2002; Moynihan, &
Pandey, 2007; Scott, & Pandey, 2005). This seems to suggest that red tape may also be
negatively associated with job satisfaction at the individual level. Interestingly, scholars argue that the findings of red tape at organizational level may translate to employees’
experiences of red tape at the individual level (DeHart-Davies, & Pandey, 2005; Pandey, &
Kingsley, 2000; Scott, & Pandey, 2002). However, this relationship is – to my knowledge – not empirically tested. In congruence with previous research, I expect that:
Hypothesis 1b: Individual red tape is negatively related to job satisfaction.
The Moderating Role of Voice
Quratulain and Khan (2015) argue that there is much to discover about the underlying mechanisms between red tape and individual outcomes. Voice may be one of those
underlying mechanisms and may alleviate the positive (negative) link between red tape and job stress (job satisfaction). Boxall and Purcell (2003) define voice as “a whole variety of processes and structures which enable, and at times empower employees, directly and indirectly, to contribute to decision making in the firm”. Employee voice can either be
expressed directly or indirectly. Indirect voice occurs when employees are required to consult a third party higher up to influence decisions. Direct voice, in contrast, refers to the directly influencing decisions by employees higher up without requiring a third party (Forth, &
Millwards, 2002). More specifically, voice provides employees with the opportunity to communicate their concerns and opinions and that may influence organizational decisions (Bryson, Gomez, Kretschmer, & Willman, 2007; Dundon, & Gallon, 2007).
Interestingly, in the context of healthcare, Irvine and Evans (1995) showed that routinization, standard operating procedures, and participation in decision making all are related to healthcare professional’s self-reported job satisfaction and job stress. Voice and participation in decision making are fairly similar, the latter being defined as “as a meaning that an individual who is affected by decisions influences the making of those decisions”
(Connor, 1992). Indeed, Budd, Gollan, & Wilkinson (2010) point out that voice and
participation are very broad concepts with a range of definitions that sometimes overlap each other.
Previous research shows that participation in decision making may alleviate some of the the job demands – turning a must into a should- that people face as they have an
opportunity to voice concerns and make suggestions to improve their work procedures (Beh,
& Loo, 2012; Hobfoll, & Freedy, 1993; Holland et al., 2013; Wilkinson, & Fay, 2011). For instance, Lui and colleagues (2015) showed that a high level of participation in decisions may increase job satisfaction and empowerment because it reflects the organization’s concern for employee well-being (absence of stress) and success. Lam, Chen, and Schaubroeck (2002) stated that participation in decision making helps employees to achieve work-related goals, which will provide them with a feeling of mastery and satisfaction over their work. Further, research by Cai (2004) indicated that participation in decision making enables employees to better understand the decisions and at the same time reduces the misunderstandings and unhappy feelings – such as stress – among employees. Also, participation in decision making is found to be positively related to job satisfaction (Locke, & Schweiger, 1979; Melcher, 1976, Zhu, Xie, Warner, & Guo, 2015).
All in all, I argue that voice acts as a moderator such that voice alleviates, the positive link between red tape and job stress and the negative link between red tape and job
satisfaction. Specifically, I expect that higher levels of voice make healthcare professionals experience red tape less negatively. As such, I contend that:
Hypothesis 2a: The positive relation between red tape and job stress is moderated by Voice, so that this positive relation is most strong when there is low voice.
Hypothesis 2b: The negative relation between red tape and job satisfaction is moderated by Voice, so that this negative relation is most strong when there is low voice.
Method
Respondents and Procedure
Data from 207 care providers was used to test the aforementioned hypotheses. All variables were tested at the individual level and respondents were spread over different healthcare professions in the Netherlands, including nurses (13.99%), physician assistants (5.34%) and doctors (5.34%). Of 243 participants, 36 were excluded from further analyses as they did not complete the questionnaire entirely. Among the 207 participants, 12.7% were men (𝑀
𝑎𝑔𝑒= 45.44, 𝑆𝐷
𝑎𝑔𝑒= 12.33) and 87,3% were women (𝑀
𝑎𝑔𝑒= 40.75, 𝑆𝐷
𝑎𝑔𝑒= 12.57).
The average work experience of the respondents was 17.4 years (SD = 12.7). The level of education of the respondents is distributed as followed: 29.6% holds a master’s degree or higher, 29.6% a bachelor degree, 19.3% a vocational degree, 4.1% a high school degree, 0.8% a primary school degree.
Participants were approached via e-mail, telephone, or in person. The participants were told that the questionnaire was about work perceptions and that it was available to them both online (via Qualtrics) as well as in paper-and-pencil form and that it would take
approximately 10 minutes to complete. It was stressed that participation was voluntary and that responses would be treated confidentially and anonymously. First, participants read and signed the informed consent. Next, participants completed the red tape, voice, job stress, and job satisfaction questions. Finally, participants completed some demographical questions, after which they were thanked for their participation.
Measures
Red Tape. This variable was assessed using a self-made scale (see Appendix A) based
on previous research by Feeney (2012), Pandey et al. (2007) and Spector (1985). This 7-item scale includes items such as: “In my organization there are too many rules and procedures”
and “In my organization formal procedures often take too much time”. The participants
indicated their agreement with the statements using a 7-point Likert-type rating scale(1 =
completely disagree, 7 = completely agree), and all items were averaged to form a single red tape score (M = 3.82, SD = 1.30, α = .92).
Job Stress. This variable was assessed by using a 4-item job stress scale based on
previous research by Motowidlo, Packard, and Manning (1986). This 4-item scale includes items such as: “My job is extremely stressful” and “Very few stressful things happen to me at work”. The participants indicated their opinion using a 7-point Likert-type rating scale (1 = completely disagree, 7 = completely agree). Two of the items were reverse-scored and recoded before all items were averaged to form a single job stress score (M = 4.30, SD = 1.17, α = .78).
Job Satisfaction. This variable, consisting of four items, was assessed by using the 4-
item overall job satisfaction scale by Mitchell, Holtom, Lee, Sablynski, and Erez (2003).
Examples items are: “I find real enjoyment in my job” and “Most days I am enthusiastic about my job”. The participants rated these statements using a 7-point Likert-type rating scale (1 = completely disagree, 7 = completely agree), and all items were averaged to form a single job satisfaction score (M = 5.43, SD = 1.05, α = .91).
Voice. This variable was measured using the 4 items of the “participation in decision
making”-subscale of the centralization scale by Schminke, Cropanzano, & Rupp (2002).
Examples of items included are: “How frequently do you usually participate in the decisions on the adoption of new programs?” and “How frequently do you usually participate in the decisions to hire new staff?”. The participants rated these statements using a 7-point Likert- type rating scale (1 = completely disagree, 7 = completely agree). All items were averaged to form a single voice score (M = 2.99, SD = 1.58, α = .87).
Results
Preliminary Analyses
The mean, standard deviations, reliabilities, and intercorrelations are presented in Table 1. Hypothesis 1 was tested using a simple regression analysis. For Hypothesis 2, two separated moderation regressions were conducted using Hayes’ (2013) PROCESS-macro in SPSS. Prior to these moderation analyses, the variables red tape and voice were mean- centered (cf. Hayes, 2013).
Hypothesis Testing
Hypothesis 1a states that red tape is positively associated with job stress. A simple regression analysis confirmed this hypothesis, 𝑏 = .23, 𝑆𝐸
𝑏= .06, 𝑡(205) = 3.87 , 𝑝 <
.001. Hypothesis 1b states that red tape is negatively associated with job satisfaction. A simple regression analysis yields support for this hypothesis, 𝑏 = −.20, 𝑆𝐸
𝑏= .05, 𝑡(205) =
−3.66 , 𝑝 < .001.
Hypotheses 2a and 2b involve moderation regression analyses (cf. Hayes, 2013).
Hypothesis 2a states that the positive relation between red tape and job stress is stronger for
lower levels of voice compared to higher levels of voice. A hierarchical linear regression
analysis was conducted with red tape as the independent variable and with job stress as the
dependent variable. Results showed that Step 1 explained a significant proportion of the
variance, 𝛥𝑅
2= .12, 𝛥𝐹 (3,203) = 9.25, 𝑝 < .001. There was a main effect for red tape,
𝑏 = .26, 𝑆𝐸
𝑏= .06, 𝑡(203) = 4.40, 𝑝 < .001, showing that participants’ job stress is higher
when perceived red tape is higher. Step 2 explained an additional significant proportion of
variance in job stress, 𝛥𝑅
2= .03, 𝛥𝐹 (1,203) = 5.97, 𝑝 = .02, and uncovered the predicted
interaction between red tape and voice, 𝑏 = −.08, 𝑆𝐸
𝑏= .03, 𝑡(203) = −2.44, 𝑝 = .02. In
line with Hypothesis 2a (1 SD above and below the mean), red tape was only strongly
positively associated with job stress for lower levels of voice, 𝑏 = .40, 𝑆𝐸
𝑏= .09, 𝑡(203) =
4.50, 𝑝 < .001, but not for higher levels of voice, 𝑏 = .13, 𝑆𝐸
𝑏= .07, 𝑡(203) = 1.74, 𝑝 =
.08.
Hypothesis 2b states that the negative relation between red tape and job satisfaction is strongest for lower levels of voice. A hierarchical linear regression analysis was conducted with red tape as independent variable and with job satisfaction as the dependent variable.
Results showed that Step 1 explained a significant proportion of the variance, 𝛥𝑅
2= .11, 𝛥𝐹 (3,203) = 8.36, 𝑝 < .001. There was a main effect for red tape, 𝑏 = −.22, 𝑆𝐸
𝑏= .05, 𝑡(203) = −4.05, 𝑝 < .001, showing that participants’ job satisfaction is lower when perceived red tape is higher. Step 2 explained an additional significant proportion of variance in job satisfaction, 𝛥𝑅
2= .02, 𝛥𝐹 (1,203) = 5.12, 𝑝 = .02, and uncovered the predicted interaction between red tape and voice, 𝑏 = .07, 𝑆𝐸
𝑏= .03, 𝑡(203) = 2.36, 𝑝 = .02. In line with Hypothesis 2b (1 SD above and below the mean), red tape was only strongly negatively associated with job satisfaction for lower levels of voice, 𝑏 = −.33, 𝑆𝐸
𝑏= .08, 𝑡(203) =
−4.15, 𝑝 < .00, but not for higher levels of voice, 𝑏 = −.11, 𝑆𝐸
𝑏= .07, 𝑡(203) =
−1.59, 𝑝 = .11.
Discussion
In the present research, I expected red tape to be positively associated with job stress and negatively with job satisfaction. Moreover, I hypothesized that voice would moderate these relationships such that the positive (negative) link between red tape and job stress (job satisfaction) is strongest when voice is low. The results are in line with these hypotheses.
Healthcare professionals’ experience of red tape was positively (negatively) associated with job stress (job satisfaction), and voice only moderated these effects when voice was low, not when it was high.
Theoretical Implications
The results suggest several implications for research on red tape, job stress, and job
satisfaction, and voice. First, previous research suggested a possible positive relation between
employees’ individual experiences of red tape and job stress (Ganster, 2008; Giauque et al.,
2013; Wittchen, Krimmel, Kohler, & Hertel, 2013). Literature also suggested that individual red tape and job satisfaction could be negatively related (Buchanan, 1975; DeHart-Davis, &
Pandey, 2005; Moynihan, & Pandey, 2007; Pandey, & Welch, 2005; Scott, & Pandey, 2005).
The present study adds merit to the idea that red tape is not only an organizational-level construct, but that it is also an individual-level construct (Bozeman, & Kingsley, 1998;
Moon, & Bretschneider, 2002; Scott, & Pandey, 2005). The present study showed that individual experiences of red tape occur and that this individual red tape was related (positively) to job stress and (negatively) to job satisfaction. Second, red tape literature mainly focuses on its negative effects, but not so much on how these negative effects may be alleviated (cf. Feeney, 2012) The present study showed that voice may shield healthcare professionals from the positive (negative) link of red tape with job stress (job satisfaction).
As such, this study is a first step in finding ways of mitigating the negative effects that red tape may have. Third, the present study further recognizes the importance of employee voice in the workplace. Whereas providing voice (i.e. high voice) may have beneficial effects, the present study also shows that taking away voice (i.e. low voice) may have detrimental effects in the workplace in terms of job stress and job satisfaction.
Practical Implications
Besides theoretical implications, also practical implications can be derived from the present research. First, the present research showed that, on average, healthcare professionals do experience a lot of abundance of rules and procedures as red tape (cf. Duffield, &
O’Brien-Pallas, 2003; Holland et al., 2013). And that healthcare professionals’ experiences of
red tape is positively related to their experience of job stress and negatively related to their
experience of job satisfaction. As such, a first step for healthcare organizations may be to try
to reduce the amount of rules and regulations that are imposed on healthcare professionals.
Second, if healthcare organizations fail to or cannot reduce the amount of rules and regulations, they may try to provide healthcare professionals with more voice. Although not direct evidence, the present study showed that the positive (negative) link between red tape and job stress (job satisfaction) only occurred under lower levels of voice but not higher levels of voice. This seems to suggest that higher levels of voice may, at least partially, shield healthcare professionals form their negative experiences of voice.
Strengths and Limitations
As virtually all studies, the present research featured strengths, but also limitations.
One of the strengths of this research was the use of a large sample size taken form Dutch healthcare organizations. Further, it is typically difficult to get access to actual healthcare professionals due to their limited and busy time schedule. Fortunately, we – myself and other researchers with whom I collaboratively collected data – successfully managed to have healthcare professionals partake in our study. A limitation of this research is perhaps that this study might not generalize to all healthcare professionals as the majority of the participants were either primary of secondary care givers and not so much physicians and medical experts. Further, given that we merely measured all variables, internal validity is low as we did not manipulate one of the variables (i.e. experiment) Lastly, the present research may suffer from common method bias as all measures were self-report measures (e.g. Podsakoff, MacKenzi, Lee, & Podsakoff, 2003).
Directions for Future Research
Future research could examine the effects of voice even closer in order to gain complete understanding about the working of this underlying mechanism between red tape and individual outcomes.
Second, the current research model could be extended by incorporating how the
researched individual level outcomes (i.e. job stress and job satisfaction) affect organizational
outcomes and overall performance and quality of care in order to gain a more clear and complete picture of how red tape truly and completely affects not only healthcare
professionals, but also other stakeholders such as the healthcare organization and patients.
Also, future research could adopt a different research paradigm to see whether providing healthcare professionals with more voice actually works. For instance, it would be interesting to perform an intervention study where one group is given more voice than
another group and to compare whether the high voice group indeed suffer less from red tape.
Conclusion
In sum, this research shows a positive relation between red tape and job stress and a negative relation between red tape and job satisfaction. More importantly, the present research showed that voice moderated such that said effects occurred when voice was low, but not when high. This suggest that not giving voice to healthcare professionals is
detrimental when they experience red tape, but that providing healthcare professionals with
voice may shield them against their negative experiences of red tape. Future research could
focus more on how these findings affect the organization at large and other stakeholders and
an intervention study may be conducted to portray a clearer and more complete picture of
healthcare professionals’ negative experiences of red tape.
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Table 1
Means, standard deviations, reliabilities, and intercorrelations for the study variables
M SD (1) (2) (3) (4)
(1) Red tape 3.82 1.30 .92
(2) Job satisfaction 5.43 1.05 -.25** .91
(3) Job stress 4.30 1.17 .26** -.20** .78
(4) Voice 2.99 1.58 -.02 .17* .16* .87
Note. N = 243. Cronbach’s alphas are displayed on the diagonal.
* p < .05; ** p < .01.
Figure 1. Job Stress as a Function of Red Tape and Voice.
3 3,2 3,4 3,6 3,8 4 4,2 4,4 4,6 4,8 5
Low RTAPE High RTAPE
Job S tr ess
Low VOICE
High VOICE
Figure 2. Job Satisfaction as a Function of Red Tape and Voice.
3,5 4 4,5 5 5,5 6 6,5 7
Low RTAPE High RTAPE
Job S atisf ac tion
Low VOICE
High VOICE
Appendix A Red Tape Measure
In my organization…
1 … there are too many rules and procedures.
2 … the rules and procedures keep me from working effectively.
3 … the formal rules make it difficult to start a new project.
4 … many of the rules and procedures make doing a good job difficult.
5 … my efforts to do a good job are often blocked by red tape.
6 … I often have too much paperwork.
7 … formal procedures often take too much time.
8 … I have to follow rules and procedures against better judgment.
Note: Response Scale: 1= Completely Disagree; 7 = Completely Agree. Items adapted from Feeney’s (2012) one-item red tape measure.
