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T H E J O U R N A L O F N U R S I N G A D M I N I S T R A T I O N

Wired to the Workplace The Relationship Between Electronic Connectedness to Work and Nurse Manager Satisfaction

Candace Gardner, MSN, RN

Amy Hailey, MSN, RN

Christi Nguyen, DNP, RN

Charlsea Prichard, MSN, RN

Patricia Newcomb, PhD, RN

OBJECTIVE: The aim of this study is to describe the beliefs and behaviors of nurse leaders regarding elec- tronic connectedness with their workplace and work- place support. BACKGROUND: Electronic communication enables leaders_ continuous availability to the workplace. This may blur home-work boundaries and contribute to burnout. METHODS: This mixed-methods study surveyed nurses in 6 acute care hospitals in north Texas. A qualitative phase employed focus groups composed of nurses from participating hospitals to validate and enrich data collected in the quantitative phase. RESULTS: Data showed that leader support directly influenced work-related electronic communication by influencing expectations regarding connectedness. Furthermore, leaders who frequently thought of leav- ing employment reported significantly lower levels of supervisor support and stronger beliefs that work interfered with home life than other respondents did. Focus group data supported survey findings. CONCLUSIONS: Electronic availability of nurse lead- ers did not directly affect satisfaction, but supervisor support and perception that work interferes with home life strongly and directly affected satisfaction.

Nurse leaders are exposed to intense and persistent stressors resulting in high risk for burnout.1 Seminal work by Maslach2 in the 1970s developed the con- cept of burnout in the helping professions as chronic negative emotional responses that result in reduced job satisfaction, increased rates of absenteeism, and increased rates of turnover. The perceived demand to be persistently available, physically or electroni- cally, is 1 of many stressors for nurse leaders that may promote burnout. Like other professionals, nurse leaders identify the electronic tether that binds them to the workplace as a means to increase productivity, but also as a major stressor.

Background

Most evidence regarding the effects of workplace e-mail on workers is emerging from fields interested in human-computer interaction, such as computer science, business, and psychology. According to a recent Center for Creative Leadership survey of executives, managers, and professionals (EMPs) globally, most EMPs use mobile phones for work, remaining con- nected electronically to the workplace for about 13.5 hours daily during the business week and 5 hours daily on weekends.3 In the same survey, 60% of the subgroup of EMPs who used smartphones remained connected to work for 13.5 to 18.5 hours daily, whereas only 29% of EMPs who did not connect by means of smartphones worked as long.3 Results of a similar survey by the American Psychological Asso- ciation_s Center for Organizational Excellence showed that more than half of all employed adults check work- related e-mails before or after work on weekdays, on the weekend, and when they are sick.4 Data collected

16 JONA � Vol. 47, No. 1 � January 2017

Author Affiliations: Staff Educator (Ms Gardner); Assistant Chief Nursing Officer (Ms Hailey); Manager, Trauma Intensive Care Unit (Ms Prichard), Texas Health Harris Methodist Hospital, Fort Worth; Manager, Texas Health Presbyterian Dallas Hospital (Ms Nguyen); Nurse Scientist (Dr Newcomb), Texas Health Resources, Arlington.

The authors declare no conflicts of interest. Correspondence: Ms Gardner, Center for Advancing Profes-

sional Practice, 701 5th Ave, Fort Worth, TX, 76104 (Candace Gardner@texashealth.org).

DOI: 10.1097/NNA.0000000000000431

mailto:CandaceGardner@texashealth.org

by Szostek indicate that workers treat email as a syn- chronous activity and feel the need to respond im- mediately. In turn, they expect immediate responses to their own messages.5 The electronic technology that promised increased flexibility in work scheduling may result in making workers so available that they are essentially never off work.

Furthermore, age disparities may be involved in how employees perceive electronic communication. Younger employees have been found to complain more than older employees that electronic commu- nications negatively affect their relationships outside of work and cause them to work faster than they want.4

The implication of age disparities for nursing may be substantial because the rapid aging of the nursing workforce is increasing the demand for younger nurse leaders in acute care settings. Fewer than 50% of nurses now working in acute care settings are 50 years or older, while 85% of nurses in the hospital setting are 30 years or younger, but members of Generation X and Y, those born after 1979, show little interest in applying for frontline nurse leader positions.6 Excessive reliance on electronic connectedness to workplace activity may further alienate this group from leadership roles.

Studies outside of nursing and healthcare have shown that electronic communication in the workplace can have adverse effects on workers, including anxiety, longer work hours, feelings of isolation and loss of control, work overload, task fragmentation, faster work pace, and e-mail addiction.7 However, in the nursing literature, specifically, studies of the effects of electronic communication on nurses or nurse managers are sparse, perhaps nonexistent. With the exception of a single com- mentary,8 a search of CINAHL and Medline revealed no studies or even discussion in Healthcare-related scholarly journals in the past 5 years regarding the effects of e-mail and texting in the nursing work environment.

In summary, advances in electronic communica- tion technologies have enabled leaders to be continu- ously available to the workplace regardless of physical location, and this may be blurring the boundaries between home and work, overwhelming leaders with trivial tasks, and contributing to burnout. In addition, the impact of electronic technology on job satisfaction may be more negative in younger leaders. Burnout among nurse leaders is a serious issue for hospitals in the United States because such leaders leave their posi- tions, perpetuating an existing nursing shortage.6 Cur- rent literature supports the need for further studies of electronic job satisfiers and stressors among all nurse leaders, especially those in younger age cohorts.1,8-10

Purpose

The purpose of this study was to describe the beliefs of nurse middle managers regarding work-related elec-

tronic connectedness and workplace support, as well as to measure the strength of the association between in- tention to change employment and beliefs regarding workplace connectedness and support.

Methods

The study was reviewed and approved by the insti- tutional review boards governing research on human subjects in the participating hospitals. The study qualified for alteration of the process of informed consent under 45 CFR 46.116 (d)1-4 and waiver of documentation of informed consent under 45 CFR 46.117 (c).1,2

The study used a mixed methods approach including (1) a survey of nurse leaders and directors across 6 acute care hospitals in north Texas and (2) focus groups in the 2 largest participating hospitals. Hospital size ranged from 255 to 900 beds. All hos- pitals in the hospital system that were either MagnetA- designated or on the journey were eligible to participate.

An a priori power analysis determined that a sample of 70 subjects would be sufficient to answer the primary research questions using a cross-sectional survey design, multivariable data analysis, and assum- ing moderate effects.11 The pool of potential partici- pants included all nurse leaders or directors in the participating hospitals and contained approximately 160 individuals. All were offered the survey. A sample of 109 responses was returned (68% response rate).

A list of nurse leaders at the participating hospitals was obtained from the human resources department or the chief nursing officer (CNO) at each hospital. All exempt nurse leaders at the manager and director level were eligible to participate. Participants were recruited by means of e-mail messages describing the study and inviting them to participate. Recruitment e-mails directed potential participants to a link that opened an electronic survey over a 3-week period. Reminder e-mails were sent 10 days after the 1st invitation. No further contact was made with potential participants.

Procedures

The BWired to the Workplace[ survey was designed by the investigators, including 4 nurse managers, a nurse director, and a nurse researcher. Content validity was established by participation in the tool develop- ment process of 6 nurse leaders thought to be content experts regarding e-mail and texting communication in the nursing workplace by virtue of their recent practice experience and familiarity with the target technologies. Tool developers brought a combined experience of approximately 50 years in nursing management. Con- sistency of instrument results with focus-group find- ings was also assessed to provide evidence of congruent

JONA � Vol. 47, No. 1 � January 2017 17

validity. The survey tool consisted of 45 items. Items 34 to 45 elicited demographic data. The first 33 items elicited information regarding use of electronic media for work-related communication, influence of work practices on family relationships and work-home life balance, perception of supervisor support, and thoughts regarding leaving the organization. The tool may be obtained directly from the 1st author without charge.

Three items (BI feel my job responsibilities interfere with the quality of time I spend with my spouse or significant other,[ Bmy work schedule interferes with my home life,[ and BMy work responsibility to be available 24 hours/day, 7 days/week interferes with my home life[), composed a Home subscale relating to effects of work-related communication on home life. Three items related to supervisor support composed a Supervisor Support subscale (supervisor responds to concerns about work-related stress, supervisor sup- ports efforts to take time away from the workplace to unplug, CNO responds to concerns about work-related stress). Other items were considered individually. Re- spondents were asked to rate each item on a 7-point semantic differential scale. Adjectives anchoring the ends of most item scales were Bnever[ and Balways,[ but some items were rated using different anchor pairs, such as Bsatisfied[ to Bdissatisfied, Bseldom[ to Bfrequently,[ and Bintellectually stimulated[ to Bbored.[

The survey was administered in the form of a SurveyMonkey questionnaire. Subjects received a com- plete explanation of the study in the survey cover letter that explained the purpose of the study and the pro- cedures to follow to participate in the study. The BTrack Respondents Anonymously[ option in the SurveyMonkey program, in which survey settings are arranged to Bnot save e-mail addresses,[ was used to preserve privacy and confidentiality.

Six focus groups were organized after the surveys. Groups contained 9 to 12 participants, for a total of 51 participants. Potential focus group participants were invited from the 2 largest institutions in the study. Each focus group was led by 1 of 2 nurse researchers from the participating healthcare systems. Focus group leaders conducted groups using a semistructured interview guide, which included selected questions from the sur- vey for the purposes of assessing survey validity as well as obtaining increased richness of information. All data collected from participants were deidentified and treated as confidential.

Data analysis consisted of descriptive statistics to characterize the sample and to describe the responses to the survey, multivariable regression to model rela- tionships between workplace attitudes and e-mail communication behaviors away from work, and analy- sis of variance to compare age cohorts on selected variables. Focus group data were subjected to content

analysis using conventional conceptual and relational coding as described by Krippendorf.12

Results

Survey

Internal consistency reliability for items 1 to 33 was good (Cronbach_s ! = .88). ! Values for the super- visor support subscale was .84 and for the home subscale was .92, indicating excellent reliability for short scales. Table 1 reports the characteristics of the sample and Table 2 reports frequencies for responses on items relevant to this report. Because generational differences were of interest, responses are reported for the total sample and for 2 age cohorts: respondents born in 1960 or earlier and those born after 1960.

Factors Affecting Response to E-mail

Most respondents (77%) felt obligated to check work- related e-mails when away from work regardless of the reason for being away. Younger leaders were signi- ficantly more likely to check e-mails in all circum- stances than older leaders were, but in other respects, their behavior was similar to that of their older col- leagues. Three factors were responsible for most of the variance (52%) in checking e-mails away from work (R2 = 0.52). As shown in Table 3, respondents who felt obligated to check work-related emails when away from work were (1) more likely to believe that direct reports expected them to check e-mails when away from work, (2) more likely to believe that their super- visor expected them to check e-mail when away from work, and (3) more likely to feel that ignoring e-mails when away from work made work harder when they returned. Results were similar when the situation was narrowed to checking e-mails on scheduled vacation days. When the situation involved checking e-mail when ill, the influence of supervisor expectations diminished to insignificance and the fear of increased workload and staff expectations increased in influence, indicating that managers believe there that is some slack in supervisor expectations during illness. There was a weak, but sig- nificant, correlation (r = 0.32) between feeling obli- gated to check e-mail when away from work and the expectation that one_s own supervisor would check electronic messages from the respondent when the supervisor was away from work, supporting the notion that modeling plays a role in e-mail behavior.

Supervisor Support and Desire to Leave Employment

Supervisor support was significantly and negatively correlated (r = j0.560) with thinking of seeking em- ployment elsewhere. The less support the respondent perceived from his/her supervisor, the more likely the respondent was to think frequently of leaving. Scores

18 JONA � Vol. 47, No. 1 � January 2017

on the supervisor support and home indexes predicted 40% of the variance in frequency of thinking of leaving current employment, with standardized " coefficients of j.397 and .361, respectively, and P values less than .0001 for each factor. Perceived sup- port of the supervisor was the most important (largest) predictor for thinking of leaving employment.

Focus Groups

For the purposes of this report, we focus on the content related to supervisor support because surveys showed that supervisor support played the strongest role in leaders_ considerations of leaving employment and was related to electronic communication. Focus group respondents identified 4 clusters of supervisor behav- iors they found supportive (Figure 1), including culti- vating trust, constructing empathetic relationships, establishing effective communication, and setting limits. Content was consistent with questionnaire findings, providing additional evidence of questionnaire validity.

Cultivating Trust Between Middle Managers and Their Supervisors Supervisor behaviors that leaders highlighted as eroding trust included micromanaging, dishonesty, and reluctance to listen to criticism. Respondents identified micromanagement as deeply damaging be- havior because it implied the supervisor could not trust the leader to do his/her job, thus injuring leader self-esteem and confidence. Constant surveillance and attempts to control the leader_s work built resentment and frustration, as well as inhibiting productivity.

Nurse leaders want supervisors who are honest with them. In focus group discussions, the term

honesty referred to alignment of the supervisor_s behavior with the supervisor_s espoused values and claims. With regard to electronic communication, some respondents distrusted supervisors who said it was BOK[ to disconnect but whose behavior indi- cated disconnection was not really acceptable. Re- spondents remained connected even when they thought it inappropriate in such cases.

Finally, leaders claimed that supervisor re- sponses to criticism have a substantial impact on trust. Supervisors who listened to critiques of orga- nizational processes or personal behaviors, deliber- ated, and avoided retaliation were perceived as more trustworthy than supervisors who were reluctant to hear criticism. As this discussion evolved, the theme of leader anxiety emerged. Fear of retaliation against criticism served as a stepping stone to discussion of other fears, notably fear of reprimands targeting leaders who make mistakes. On the other hand, leaders who described relationships with trusted supervisors men- tioned open communication and mutual problem solving. These supervisors made the leader feel valued and free to speak plainly.

Construct Empathetic Work Relationships Respondents perceived the empathy of supervisors as essential for building trust and communicating effec- tively. Respondents identified 2 factors as important for constructing empathetic relationships, including setting aside time for regular face-to-face meetings between middle managers and their supervisors and using active listening to recognize and acknowledge the work stresses experienced by the other person.

Table 1. Sample Characteristics

Characteristic

Total Sample (Includes Post-1981

Births), % Birth Pre-1961 (Boomers), %

Birth 1961-1981 (GenX), %

Difference Between Age Cohorts

(Fisher Exact)

Female 92 96 88 NSD 0-3 years in current position 59 52 65 NSD 4-10 years in current position 29 28 31 NSD G10 years in current position 12 20 4 P = .03 0-3 years_ total experience as

manager/director 26 18 35 NSD

4-10 years_ experience as manager/director

41 24 59 P = .001

G10 years_ experience as manager/director

32 58 6 P = .0001

Married 79 78 80 NSD Is Bmajor breadwinner[ in family 63.3 76 65 NSD Daily commute G60 min 23 20 33 NSD Children at home 82.8 82.2 81.6 NSD White 75.2 86.7 79.6 NSD Health is source of anxiety 20.2 20 24.5 NSD

Abbreviation: NSD, no significant difference.

JONA � Vol. 47, No. 1 � January 2017 19

Establish Effective Communication at Work Respondents identified 3 behaviors that they believed supervisors should use to establish effective commu-

nication with subordinate leaders. First, they wanted supervisors to use affirming language with their subor- dinates. Words that devalue the leadership abilities of

Table 3. Why Respondents Check Work-Related E-mails When Away From Work

Predictor Standardized " P

Factors that predict feelings of obligation to respond to e-mail when away from work for any reason. Fear that workload will increase if e-mails aren_t immediately addressed .332 .0001 Direct reports expect managers/directors to respond to e-mails when away from work .323 .0001 Belief that supervisor expects manager/director to check e-mail when away from work .236 .001

Factors that predict feelings of obligation to respond to e-mail when away from work for scheduled vacation Fear that workload will increase if e-mails aren_t immediately addressed .397 .0001 Direct reports expect managers/directors to respond to e-mails when away from work .260 .003 Belief that supervisor expects manager/director to check e-mail when away from work .240 .005

Factors that predict feelings of obligation to respond to e-mail when away from work for illness Fear that workload will increase if e-mails aren_t immediately addressed .417 .0001 Direct reports expect managers/directors to respond to e-mails when away from work .330 .001

Table 2. Responses to Selected Survey Statements

Item

Total Sample

(N = 109)

Birth 1960 or Earlier

(n = 45a)

Birth Post-1960 (n = 54a)

Statistical Difference Between

Age Cohorts

Feels obligated to check work-related e-mails when away from workplaceb

5.6 (1.7) 5.5 (1.7) 5.7 (1.8) NSD

Ignoring work-related e-mails when away from work makes the subject_s workload harder after returning to workb

6.1 (1.4) 6 (1.3) 6.2 (1.4) NSD

Checks work-related e-mails when on scheduled vacation daysb

4.95 (2.1) 4.4 (2.1) 5.5 (1.8) P = .008

Checks work-related e-mails when away from workplace due to illnessb

5.3 (2) 5 (2) 5.8 (1.6) P = .04

Checks work-related e-mails after leaving work for dayb 5.5 (2) 5 (2.2) 6 (1.7) P = .008 Checks work-related e-mails on weekendb 5.8 (1.9) 5.3 (2.1) 6.3 (1.5) P = .02 Thinks supervisor expects subject to check

e-mail when away from workb 3.8 (2.1) 3.7 (2.3) 3.8 (2) NSD

Thinks direct reports expect the subject to check e-mail when away from workb

4.8 (2) 4.5 (2.1) 5 (1.8) NSD

Expects supervisor to answer e-mails from subject when supervisor is away from workb

2.4 (1.6) 2.4 (1.7) 2.4 (1.6) NSD

Director/supervisor supports subject_s efforts to take time away from work to Bunplug[b

5.35 (1.8) 5.4 (2) 5.3 (1.7) NSD

Job responsibilities interfere with quality of time spent with significant otherb

4.6 (2) 4.3 (2) 4.9 (1.9) NSD

Work schedule interferes with home lifeb 4.1 (1.9) 4 (1.9) 4.4 (1.9) NSD Responsibility to be available to work 24 hours/day,

7 days/week interferes with home lifeb 4.3 (2) 3.9 (2) 4.7 (2) NSD

Subject believes CNO would respond to concerns about work-related stressb

5 (1.9) 5.2 (1.7) 4.9 (2) NSD

Director/supervisor responds to concerns about work-related stressb

5.5 (1.6) 5.5 (1.7) 5.4 (1.6) NSD

Director/supervisor_s expectations of how often subject should check e-mailc

3.5 (2.1) 3.5 (2) 3.5 (2.3) NSD

Volume of workload makes subject feel overwhelmedd 4.9 (1.8) 4.8 (1.8) 4.9 (1.9) NSD In past year, subject has been thinking of seeking

employment elsewhered 2.5 (1.8) 2.4 (1.7) 2.6 (1.9) NSD

Data are presented as mean (SD). Abbreviations: CNO, chief nursing officer; NSD, no significant difference. aTen respondents refused to indicate birth cohort; thus, total is greater than pre- and post-1960 categories. bScale is from never (1) to always (7). cScale is from clear (1) to unclear (7). dScale is from seldom (1) to frequently (7).

20 JONA � Vol. 47, No. 1 � January 2017

subordinates made it difficult to hear the supervisor_s message. Second, respondents wanted supervisors to use positive reinforcement and avoid punishing mes- sages. Finally, respondents wanted supervisors to respect whatever chain of communication hierarchy existed. They wanted to receive work-related messages from their immediate supervisor rather than a supervisor further up in the chain of command. Respondents who felt this way believed that bureaucratic layering offered some protection to them and felt less anxious about communicating with an immediate supervisor than a more removed superordinate.

Setting Limits In general, respondents agreed that work-related elec- tronic communication was often overwhelming. One director reported having what she believed was panic attacks at meetings or events in which her cell phone had to be shut off. Her experience was echoed by other respondents who were unable to disconnect from their electronic devices long enough to accom- plish even simple household chores, such as lawn mowing or preparing a meal. Respondents believed that supervisor support was essential to the process of managing electronic connectedness to work. Respon- dents suggested 3 strategies for supportive supervisors to use in the effort to control electronic communica- tion including: (1) clarification of the supervisor_s ex- pectations for workplace connectedness; (2) giving subordinate leaders explicit permission to set limits on electronic communication; and (3) supervisor model- ing of limit setting.

Discussion

Survey and focus group findings suggested the con- ceptual model presented in Figure 2 to explain the

most salient influences on electronic connectedness to the workplace. Younger nurse managers were significantly more likely to check e-mail when away from work for any reason, but electronic communica- tion did not directly affect thoughts of leaving em- ployment in any age group. On the contrary, electronic connectedness appeared to function as a coping mech- anism. Respondents used persistent electronic connec- tion to cope with anxieties related to overwhelming workloads, reprimands from supervisors, and concerns of subordinates. Perceived supervisor support and per- ceptions regarding work interference with home and family did directly affect manager satisfaction.

Study findings lead to further questions. If elec- tronic connectedness is not a dissatisfier for nurse leaders and helps them cope, is it psychologically healthy for leaders and should it be encouraged? The American Psychiatric Association suggested including the diag- nosis Bpathological computer use[ in a recent revision of the Diagnostic and Statistical Manual of Mental Disor- ders, Fifth Edition.13,14 Excessive e-mail and text mes- saging were conceptualized as a subtype of the proposed diagnosis. The merits of medicalizing human-technology interactions are open to question,14 but the fact that the behavior surfaced as a potential pathology may be of cautionary interest for nurse leaders. Nurses in this sample seemed ambivalent as a group, using e-mail on the one hand for coping and, on the other hand, wish- ing to set limits on the practice. Although respondents in this sample did not report electronic communication as an influence on thoughts of leaving the organization, a substantial fraction still perceived it as intrusive. These findings and literature documenting the addictive nature of electronic communications support setting limits. Study respondents suggested numerous strategies for curtailing unnecessary electronic workplace connec- tions as shown in Figure 1, including setting clear limits

Figure 1. Which superordinate activities do nurse managers and directors perceive as supportive?

JONA � Vol. 47, No. 1 � January 2017 21

on electronic communication. Findings suggest that modeling limit setting to subordinate leaders can build trust and enhance nurse leader satisfaction.

Limitations

Limitations of the study, conducted among middle managers in US hospitals, include the usual potential for sampling error, that is, the possibility that members of our sample differ in random ways from the population we hope they represent. Coverage error, that is, bias that results when the pool of potential survey par- ticipants does not include some potentially eligible sample members, is also a possibility because the lists of leaders obtained from the human resources de- partments or CNOs at individual hospitals may have been incomplete. Because cultural differences that influence nursing manager communication may exist between regions of the United States, measurement

error may limit generalizability to the region in which the study was conducted.

Conclusion and Implications for Practice

Nurse leaders are tightly Bwired[ to the workplace. Most of them frequently or always remain connected electronically to work when they are away from the workplace, but persistent connection to the workplace can erode quality of life and contribute to burnout. An important strategy for curtailing unnecessary e-mail/ texting is for supervisors to agree on clear limits on electronic communication, communicate those limits plainly to subordinates, and comply with the limits themselves. This single step can contribute to the process of building trust between middle managers and their supervisors, which in turn can enhance perception of supervisor support and promote reten- tion of nurse managers.

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