The Cost of Rules and Regulations in Healthcare Organizations: The Mediating Role of Healthcare Professionals’ Experience of Job Autonomy Threat in the Link Between Coercive
Bureaucracy and Counterproductive Work Behavior and the Moderating Role of Rule Ambiguity
Margriet Buma (s2372290) University of Groningen
Department of Human Resource Management and Organizational Behaviour Nettelbosje 2, 9747 AE Groningen, The Netherlands
E-mail: margriet_buma5@hotmail.com
Word count: 4467
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 Margriet Buma,
Abstract
Healthcare organizations are growing in size and become more complex. To be cost-effective, they transform into more (coercive) bureaucracies. This research argues that
healthcare professionals’ coercive bureaucracy experiences are associated with perceptions of job autonomy threat which, in turn, relate to higher levels of counterproductive work
behavior. Moreover, it is argued and shown that rule ambiguity moderated this mediation. Rule ambiguity moderated the positive and indirect effect of coercive bureaucracy on counterproductive work behavior via perceived threats to job autonomy, but only when rule ambiguity was high. Possibly, ambiguous rules gives people more room to aggress against the threats to their autonomy due to their experiences of red tape. More practically, the negative link between red tape and counterproductive work behavior via threat to autonomy may be alleviated by implementing more clear and direct rules and procedures. Data was gathered via a questionnaire distributed amongst 243 Dutch healthcare professionals.
The Cost of Rules and Regulations in Healthcare Organizations: The Mediating Role of Healthcare Professionals’ Experience of Job Autonomy Threat in the Link Between Coercive
Bureaucracy and Counterproductive Work Behavior and the Moderating Role of Rule Ambiguity
We currently face a healthcare costs epidemic (Chapman, Kern, & Laguecir, 2014) and healthcare costs are expected to keep increasing in the coming years (e.g.,
Wubulihasimu, Gheorghe, Slobbe, Polder, & van Baal, 2015). A major part of these costs can be attributed to counterproductive work behavior, which is estimated to cost organizations several billions of dollars every year (Bennet & Robinson, 2000). Although hospitals
improved their cost-effectiveness by increasing formalization in order to accommodate their greater size and complexity (Hetherington, 1991; Stevens, Philipsen, & Diederiks, 1992), there is also a flipside when such a bureaucracy becomes coercive. That is, the abundance of routines and procedures often associated with such formalization may be experienced as unnecessary and frustrating by healthcare professionals (Rossel, 1971). This frustration may result in dysfunctional behaviors, such as counterproductive work behavior (cf. Thompson, 1961), which is characterized by acts that are "harmful to the organization by directly affecting its functioning or property, or by hurting employees in a way that will reduce their effectiveness" (Fox, Spector, & Miles, 2001 p. 292).
professionals’ job autonomy may be compensated for (e.g., Radel, Pelletier, Sarrzin, & Milyavskay, 2011) by engaging in counterproductive work behavior as a reaction to their unmet autonomy needs and create a feeling of relief and satisfaction (Dalal, 2005). As such, the present research focuses on job autonomy threat as a mediator between coercive
bureaucracy and counterproductive work behavior.
In the present research, it is argued that that this negative link may be alleviated by rule ambiguity. In situations where rules and procedures are ambiguous there is little
agreement on the exact nature of correct interpretation and therefore healthcare professionals can interpret the rules in their favor (Feldman, 1991). In such situations of high rule
ambiguity, healthcare professionals may perceive coercive bureaucracy as less threatening to their autonomy as they see chance to wiggle and may bend the rules as they see fit, feeling less affected by coercive bureaucracy. Subsequently, they may be less prone to engage in counterproductive work behavior.
All, in all, the present research aims to provide a theoretical contribution by disentangling if and why coercive bureaucracy might be positively related to
counterproductive work behavior. On a more practical note, high rule ambiguity may
alleviate the unfavorable link between coercive bureaucracy and threat to job autonomy and, in turn, healthcare professionals’ displays of counterproductive work behavior.
Coercive Bureaucracy and Counterproductive Work Behavior
Bureaucracy in organizations can be described as a set of structural arrangements involving high degrees of specialization and division of labor, routines, and standard
individuals to be effective, and decreases experienced job stress. Second, coercive
bureaucracy refers to a negative view, characterized by suppressing creativity, stimulating discontent, and demotivating employees. Not surprisingly, therefore, coercive bureaucracy has been found to have a negative effect on employees’ well-being (Adler & Borys, 1996).
Relating to healthcare professionals, coercive bureaucracy has been found to result in increased absenteeism, higher turnover intentions, and more physical and psychological stress (Rousseau, 1978). This seems to suggest that coercive bureaucracy may be positively associated with counterproductive work behavior, which can be defined as acts that are “harmful to the organization by directly affecting its functioning or property, or by hurting employees in a way that will reduce their effectiveness” (Fox et al., 2001, p. 292). This may include abusive and disrespectful treatment of others, damaging property, theft, and
unauthorized withdrawal from work (Spector, Fox, Penney, Bruursema, Goh, & Kessler, 2006). Counterproductive work behavior further includes sabotage, loafing, daydreaming, absenteeism, and vandalism (Robbinson & Bennet, 1995) and is found to occur in 75 to 95 percent of all employees to a certain extent (Harris & Ogbonna, 2006).
often a predictor to counter productive work behavior (Chen & Spector, 1992; Fox & Spector, 1999; Fox, Spector, & Miles, 2001; Ménard, Brunet, & Savoie, 2011; Shockley et al., 2012). Consequently, employees may try to counteract their experiences of coercive bureaucracy in an attempt to cope with this boredom and frustration by engaging in counterproductive work behavior.
All, in all, these behaviors may be displayed when employees of hospitals perceive a higher degree of coercive bureaucracy. According to numerous studies (i.e., Chen & Spector, 1992; Fox & Spector, 1999; Fox, Spector, & Miles, 2001; Ménard, Brunet, & Savoie, 2011; Shockley et al., 2012; Thompson, 1961), due to this frustration of coercive bureaucracies, healthcare employees may engage in counterproductive work behavior. Therefore, I expect that:
Hypothesis 1: Coercive bureaucracy is positively associated with counterproductive work behavior.
The Mediating Role of Threats to Autonomy
Job autonomy can be described as ‘the degree to which the job provides substantial freedom, independence, and discretion to the individual in scheduling the work and
determining the procedures to be used in carrying it out’ (Hackman & Oldham, 1975 p. 162). In the context of healthcare, Engel (1970) argued that healthcare professionals have a strong need for job autonomy and that the experience of autonomy by healthcare professionals is vital as it is found to be related to the quality of care provided by patients (e.g., Erikson, 1963; Loevinger, 1976; Rogers, 1961).
The notion of autonomy threat is reflected in Deci and Ryan’s (1987)
rewards (Deci, Koestner, & Ryan, 1999), deadlines (e.g., Amabile, DeJong, & Lepper, 1976), surveillance (e.g., Enzle & Anderson, 1993; Lepper & Greene, 1975), and orders and
directives (e.g., Reeve & Jang, 2006). Radel and colleagues (2011) demonstrated that a controlling climate leads to the experience of autonomy threat. Individuals that have the feeling that their autonomy is threatened may try to compensate for this by searching for direct substitutes to fulfill the unmet autonomy needs or to engage in different behaviors to feel less frustrated by these unmet autonomy needs. This may explain the potential positive link between coercive bureaucracy and counterproductive work behavior. The characteristics of a controlling climate – deadlines, surveillance, orders, and directives – resemble the characteristics of a coercive bureaucracy (cf. Adler & Borys, 1996; Radel et al., 2011). Similar to a controlling climate, the experience of a coercive bureaucracy may be perceived as a threat to healthcare professionals’ autonomy (cf. Burns & Stalker, 1961; Engel, 1970); Weber, 1947). Subsequently, if healthcare professionals cannot find substitutes to
compensate for their unmet autonomy needs, they may engage in counterproductive work behavior as an alternative behavior out of frustration. Indeed, numerous previous studies showed that undermined autonomy satisfaction is related to experiences of frustration (Reis, Sheldon, Roscoe, & Ryan, 2000; Ryan, Deci, Grolnick, & la Guardia, 2006; Ryan, 2005).
Taken together, coercive bureaucracy may be perceived as a threat to healthcare professionals’ autonomy. As healthcare professionals may not find a substitute or a substitute that satisfies their undermined autonomy needs sufficiently, they may compensate their undermined autonomy needs with other actions (cf. Radel et al., 2011). Counterproductive work behavior might be one of such actions. Therefore, I expect that:
Hypothesis 2: Threats to autonomy mediate the positive relation between coercive bureaucracy and counterproductive work behavior.
Further, rule ambiguity may moderate the link between coercive bureaucracy and perceived threats to autonomy. According to Feldman (1991, p. 1:46), ambiguity occurs when there is “no clear or appropriate course of action”. Particularly in situations where rules and procedures are ambiguous and when there is little agreement on the exact nature of the correct interpretation of the routines and procedures, there is no one strict formal way to reach a decision and to carry out a task (Kirkhaug & Mikalsen, 2009). This seems to suggest that when there is high rule ambiguity, healthcare employees may see the chance to wiggle and stretch the rules as they see fit, which may subsequently lower perceptions of threats to their autonomy. That is, the effect of the coercive bureaucracy on the threat to autonomy may be lower to the extent that rule ambiguity is higher. Due to the fact that healthcare employees have the opportunity to interpret these rules in their favor, they might feel a lower threat to their autonomy and therefore they might also engage less in counterproductive work
behavior. As such, unclear rules and policies may alleviate the potential positive link between healthcare professionals’ experiences of coercive bureaucracy and their displays of
counterproductive work behavior via perceived threats to their autonomy.
Hypothesis 3: Rule ambiguity moderates the positive and indirect effect of coercive bureaucracy on counterproductive work behavior through the threat to autonomy, such that the positive indirect effect of coercive bureaucracy on counterproductive work behavior is weaker when rule ambiguity is high rather than low.
Method Respondents and Procedure
17.31 years (SD = 12.73). 34.8% of the participants had a master’s degree, 34.8% had a bachelor’s degree, 22.7% had a MBO diploma, and the remaining 7.7% of the participants had degrees ranging from elementary school to gymnasium. On average, the participants worked 31.03 hours a week (SD = 10.82) and 79.2% had a permanent labor contract, 20.8% had a temporary labor contract, 2.9% were on an internship, and 1.4% had a temporary agent contract. The types of job held by the participants are diverse, including doctors (14.4%), nurses (12.8%), assistants (9.4%), care managers (3.7%), and pharmacists (2.1%).
Data was collected by approaching healthcare professionals via the researcher’s personal network, either by mail or by phone. Reliable and valid measures were used for all constructs. Participants first read a short description of the study, were informed about confidential treatment of their data, and gave their informed consent. Participants then proceeded filling out questionnaires measuring their work perceptions on coercive
bureaucracy, threats to autonomy, counterproductive work behavior, and rule ambiguity. The questionnaire concluded with demographics and participants were thanked.
Measures
Coercive bureaucracy. The degree to which healthcare professionals perceived coercive bureaucracy was assessed with a self-made 8-item scale based on different measures (e.g., Feeny, 2012; Spector, 1985; Pandey, Coursey, & Moynihan, 2007). Example items of this scale are: “In my organization there are too many rules and procedures”, and “in my organization the rules and procedures keep me from working effectively” (for all items, see Appendix A). The participants responded on a 7-point Likert-type rating scale (1 =
completely disagree, 7 = completely agree), and all items were averaged to form a single coercive bureaucracy score (M = 3.81, SD = 1.31, α = .92).
(1995). Example items of this scale are: “I have significant autonomy in determining how I do my job”, and “I can decide on my own how to go about doing my work”. The participants used a 5-point Likert-type rating scale to rate their perceptions of threats to job autonomy (1 = completely disagree, 5 = completely agree), and all items were averaged to form a single threats to job autonomy score (M = 4.71, SD = 1.36, α = .91).
Counterproductive work behavior. The extent to which healthcare professionals engage in counterproductive work behavior was assessed with a 7-item scale by Bennett and Robinson (2000). Items of this scale include: “I have taken property from work without permission”, and “I intentionally worked slower than you could have”. The participants used a 7-point Likert-type rating scale to rate their behavior (1 = never, 7 = daily), and all items were averaged into a single counterproductive work behavior score (M = 1.40, SD = 0.45, α = .71).
Rule ambiguity. The degree to which healthcare professionals perceived rule ambiguity was assessed with a 6-item scale (for all items, see Appendix B) adapted from several measures (e.g., House, Schuler & Levanoni, 1983; Rizzo, House, & Lirtzman, 1970). Items of this scale include: “In my current work I do not know what is expected of”, and “in my current work I have to work with vague directives or orders”. The participants used a 5-point Likert-type rating scale to rate their perceptions on rule ambiguity (1 = strongly disagree, 7 = strongly agree), and all items were averaged to form a single rule ambiguity score (M = 2.54, SD = 1.04, α = .82).
Results Preliminary Analyses
analyses. Reliability analyses (see Table 1) indicate that constructs were measured reliably (all α > .70). Descriptives and correlations are presented in Table 1.
Hypothesis Testing
The first hypothesis states that coercive bureaucracy is positively associated with counterproductive work behavior. In order to test this hypothesis, a regression analysis has been conducted. In line with hypothesis 1, the regression showed a significant proportion of variance, ∆R2
= .02, ∆F(1,206) = 4.238, p = 0.04. Coercive bureaucracy was positively associated with counterproductive work behavior, b = 0.05, SEb = 0.02 t(206) = 2.06, p = .04.
Therefore, the first hypothesis is supported.
For the second and third hypotheses, Hayes’ (2013) PROCESS macro was used. The second hypothesis states that perceived threats to job autonomy mediate the positive relation between coercive bureaucracy and counterproductive work behavior. Hayes’ (2013; model 4) mediation analysis was carried out to test this hypothesis. First, results revealed a partial mediation as there was a significant direct effect of the independent variable coercive bureaucracy on the dependent variable counterproductive work behaviour, b = 0.06, SEb =
0.02, t(207) = 2.43, p = .02. Further, bootstrapping revealed that threats to job autonomy did not mediate the relation between coercive bureaucracy and threats to job autonomy (estimate; -0.01; BCa CI: [-0.03 to 0.00]). That is, coercive bureaucracy was not related to
counterproductive work behaviour via higher levels of threats to job autonomy. Therefore, the second hypothesis was not supported.
carried out using Hayes’ procedure (2013; model 7). Table 2 presents the mediated moderation results. First, the results showed that the independent variable coercive
bureaucracy was positively associated with threats to job autonomy, b = .34, SEb = .07, t(203)
= 4.64, p = < .001. Second, coercive bureaucracy interacted with the moderating variable rule ambiguity to predict participants’ experiences of threats to job autonomy, b = .18, SEb = .06,
t(203) = 2.88, p = < .01. Bootstrapping reveals that this, in turn, predicted participants’ displays of counterproductive work behavior (estimate: .01; BCa CI: .004 to 0.02).
Specifically, only for higher levels of ambiguity, threats to job autonomy mediated the link between coercive bureaucracy and counterproductive work behavior (estimate: .02; BCa CI: 0.001 to 0.5) but not for lower levels of ambiguity (estimate: .006; BCa CI: -.001, 0.02). Therefore, the third hypothesis was only partially supported
Discussion
In the present research, it was predicted that coercive bureaucracy is positively related to counterproductive work behavior (Hypothesis 1). It was further hypothesized that the relation between coercive bureaucracy and counterproductive work behavior is mediated by threats to job autonomy (Hypothesis 2). Finally, I expected this mediation to be moderated by rule ambiguity on the path from coercive bureaucracy to threats to job autonomy (Hypothesis 3). There was support for the first hypothesis as coercive bureaucracy was found to be
Theoretical Implications
Considering these findings, the present study contributes to our knowledge of the extant literature on bureaucracy in healthcare organizations and its effect on healthcare professionals. First, it was empirically demonstrated that coercive bureaucracy is positively associated with counterproductive work behavior. This is in line with research that argues that a major part of the costs of the healthcare epidemic can be attributed to
counterproductive work behavior (Bennet & Robinson, 2000). For organizations to counter these increasing costs, they become more bureaucratic which is more cost-effective due to the formalization of the delivery structure (Hetherington, 1991; Stevens, Philipsen, & Diederiks, 1992). However, even though a bureaucratic organization saves costs, this research shows that this bureaucracy may be associated with counterproductive work behavior if the bureaucracy is coercive. In turn, this counterproductive work behavior is responsible for several billion of costs for organizations every year (Bennett & Robinson, 2000).
Interestingly, rule ambiguity only moderated the positive and indirect effect of
coercive bureaucracy on perceived threats to job autonomy when rule ambiguity was high but now when it was low, which is the reverse of what was hypothesized. This may be explained in the light of research on reactive autonomy. Murray (1938, p. 82) defined the need for reactive autonomy as: “To resist influence or coercion; to defy an authority or to seek
becomes threatened and that people become frustrated when they feel to do so (cf. Koestner & Losier, 1996).This may explain why the positive link between coercive bureaucracy and threat to autonomy was strongest for higher levels of rule ambiguity. Although healthcare professionals may become frustrated and act reactant either under high and low rule
ambiguity, particularly under high rule ambiguity they may act the most reactant (i.e., display counterproductive work behavior) as the ability to stretch the rules makes it easier for them to aggress against their undermined autonomy. That is, high rule ambiguity gives healthcare professionals an opportunity to act more in line with what they experience due to more vague rules and procedures, compared to low ambiguity.
Further, the present research adds to both research on ambiguity as well as autonomy. At face value, ambiguity and autonomy may seem similar because both involve the
experience of a certain amount of freedom. However, the present research showed that autonomy and ambiguity are not the same, given the relatively small correlation between the two (r = -.30, see Table 1). That is, apparently high rule ambiguity is not the same as
increased autonomy and ambiguity is not a direct substitute for autonomy. Autonomy is defined as having the freedom, independence and discretion over how the procedures in a job are executed (Hackman & Oldham, 1975). The distinction between the two may be derived from their respective definitions. Whereas ambiguity is defined as situations where rules and procedures are ambiguous and when there is little agreement on the exact nature of the correct interpretation of the routines and procedures, there is no one strict formal way to reach a decision and to carry out a task (Kirkhaug & Mikalsen, 2009). These definitions argue two separate perspectives of carrying out tasks. Autonomy refers to the discretion to carry out tasks as one pleases and ambiguity refers to the lack of direction as to how carry out tasks.
Given that healthcare professionals are found to value their autonomy highly, healthcare organizations may be easily tricked into offsetting the negative outcomes of increased bureaucracy with increasing healthcare professionals’ job autonomy. However, results of this research showed no support for the notion that the positive link between coercive bureaucracy and counterproductive work behavior occurs via higher or lower level of perceived threat to autonomy (Wang & Netemeyer, 2002). Therefore, increasing
healthcare professionals’ job autonomy may not work to offset increases in bureaucracy and other solutions are necessary.
Moreover, decreasing the level of bureaucracy would give the healthcare employees more satisfaction in the way they conduct their work. This could possibly lead to more motivated employees who would not engage in counterproductive work behavior. However, for most healthcare organizations it may be very difficult to decrease their level of
bureaucracy because to improve their cost-effectiveness they also have to increase the formalization of the delivery structure to accommodate their greater size and complexity (Hetherington, 1991; Stevens, Philipsen & Diederiks, 1992). Therefore decreasing the level of bureaucracy is almost impossible. Another possible solution for these organizations to counter the resistance would be to make the rules and procedures more explicit. If the rules are made evident and structured there will be no more room for own interpretation or to wiggle. Healthcare professionals will perceive the rules and procedures of the bureaucracy less ambiguous and therefore engage less in resistance which would save unnecessary costs.
Strength and Limitations
not always complete the questionnaire as seriously and concentrated. The statistical analyses did not reveal any specialties or outliers in any way, but no attention checks were included either. Nevertheless, a strength of this study is that actual healthcare professionals working in actual healthcare organizations participated, which means that the external validity is high. A second limitation in this study is that counterproductive work behavior is measured with self-report measures. According to Sacket (2002), self-self-report measures are related to low
admission rates. Consequently, counterproductive work behaviour effects in this study may have been underestimated. Another limitation is that the internal validity is low as no variables in the design were manipulated (i.e. experiment). Therefore, causal interferences cannot be made. Lastly, this study may have suffered from common method bias as all measures were self-report measures (cf. Podsakoff, MacKenzie, Lee, & Podsakoff, 2003).
Directions for Future Research
preferably an experiment, could focus on the underlying mechanism that explains how coercive bureaucracy and counterproductive work behavior are related. This may yield further insight into whether healthcare professionals show increased counterproductive work behavior because they act reactant or due to something alternative mechanisms.
Conclusion
In sum, the present study showed that coercive bureaucracy is positively related to counterproductive work behavior. Also, rule ambiguity moderated the positive and indirect effect of coercive bureaucracy on counterproductive work behaviour through the threats to job autonomy, but only when rule ambiguity was high and not when it was low. It seems that when the rules of a coercive bureaucracy are more ambiguous, people show
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Table 1
Means, standard deviations, reliabilities, and intercorrelations of the constructs M SD (1) (2) (3) (4) (1) Coercive bureaucracy 3.81 1.31 (.92)
(2) Counterproductive work behavior 1.40 0.45 .14* (.71)
(3) Threats to autonomy 4.71 1.36 -.30** .06 (.91)
(4) Rule ambiguity 2.54 1.04 .38** .28** -.07 (.82) Note. N = 207. Cronbach’s alphas are displayed on the diagonal.
Table 2.
Assessing Moderated Mediation Wherein the Positive Indirect Effect of Coercive
Bureaucracy on Counterproductive Work Behavior via Threats to Autonomy is Conditional on rule ambiguity
Threats to autonomy
Variable b SE t(207)
Constant 4.83 0.09 51.23***
Coercive bureaucracy -0.18 0.06 -2.88**
Counterproductive work behavior
Variable b SE t(207)
Constant 1.23 0.12 10.51***
Treats to autonomy 0.04 0.02 1.53
Coercive bureaucracy 0.06 0.02 2.43*
Conditional indirect effect
Condition Boot effect Boot SE LLCI ULCI
Weak rule ambiguity -0.01 0.01 -0.02 0.00
Strong rule ambiguity -0.02 0.01 -0.05 -0.00
Moderated mediation
Mediator Index Boot SE LLCI ULCI
Threats to autonomy -0.01 0.00 -0.02 -0.00
Appendix A – Conceptual model
Figure 1. Conceptual model
Appendix B – Measures Red Tape
Response Scale: 1 = Strongly Disagree; 7 = Strongly Agree
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.
Appendix C – Measures Rule ambiguity
Response Scale: 1 = strongly disagree, 2 = somewhat disagree, 3 = neutral, 4 = somewhat
agree, 5 = strongly agree
Please indicate your agreement with the following statements. In my current work…
1 …I do not know what is expected of me.
2 …my tasks/objectives are clearly defined. (reversed) 3 …it is clear what the goals and objectives are. (reversed) 4 …tasks are often not clear.
5 …I have to work with vague directives or orders.
