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ORIGINAL RESEARCH: EMPIRICAL RESEARCH

QUANTITATIVE

Nursing performance under high workload: a diary study on the


moderating role of selection, optimization and compensation
strategies
Anja Baethge, Andreas M
uller & Thomas Rigotti
Accepted for publication 10 September 2015

Correspondence to A. Baethge:
e-mail: baethge@uni-mainz.de
Anja Baethge Dr phil
Psychologist
Work, Organizational and Business
Psychology, Department of Psychology,
Johannes Gutenberg-University, Mainz,
Germany
Andreas M
uller Dr phil
Psychologist
Institute for Occupational Medicine and
Social Medicine, Medical Faculty,
D
usseldorf University, Germany
Thomas Rigotti Dr rer nat
Professor
Work, Organizational and Business
Psychology, Department of Psychology,
Johannes Gutenberg-University, Mainz,
Germany

L E R A . & R I G O T T I T . ( 2 0 1 5 ) Nursing performance under


B A E T H G E A . , M UL
high workload: a diary study on the moderating role of selection, optimization
and compensation strategies. Journal of Advanced Nursing 00(0), 000000.
doi: 10.1111/jan.12847

Abstract
Aims. The aim of this study was to investigate whether selective optimization
with compensation constitutes an individualized action strategy for nurses
wanting to maintain job performance under high workload.
Background. High workload is a major threat to healthcare quality and
performance. Selective optimization with compensation is considered to enhance
the efficient use of intra-individual resources and, therefore, is expected to act as
a buffer against the negative effects of high workload.
Design. The study applied a diary design. Over five consecutive workday shifts,
self-report data on workload was collected at three randomized occasions during
each shift. Self-reported job performance was assessed in the evening. Self-reported
selective optimization with compensation was assessed prior to the diary reporting.
Methods. Data were collected in 2010. Overall, 136 nurses from 10 German
hospitals participated. Selective optimization with compensation was assessed
with a nine-item scale that was specifically developed for nursing. The NASATLX scale indicating the pace of task accomplishment was used to measure
workload. Job performance was assessed with one item each concerning
performance quality and forgetting of intentions.
Results. There was a weaker negative association between workload and both
indicators of job performance in nurses with a high level of selective optimization
with compensation, compared with nurses with a low level. Considering the
separate strategies, selection and compensation turned out to be effective.
Conclusion. The use of selective optimization with compensation is conducive to
nurses job performance under high workload levels. This finding is in line with
calls to empower nurses individual decision-making.
Keywords: forgetting of intentions, nurses, nursing, performance quality, SOC,
workload

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A. Baethge et al.

Why is this research needed?


 Nurses are exposed to high workload levels due to the
unpredictability of events, interruptions and multitasking
demands, which are considered to be major threats to performance and care quality.
 Complementary to the design of work conditions, it is necessary to identify the effective individual action of nurses
that help them cope with high workload levels.

What are the key findings?


 Empirical evidence is presented which shows that nurses

is expected in the near future. One major reason for this


development is the predicted shortage in qualified nursing
staff and the growing number of chronically ill patients
both due to the ageing of populations in Western industrialized countries (Simoens et al. 2005). Nurses who deal with
a high workload need informed individual action strategies
to maintain their performance and care quality (e.g. Kalisch
& Abersold 2006). Thus, complementary to occupational
level approaches, it is of the utmost importance to identify
the effective individual actions of nurses that are used to
better cope with high workload levels, to maintain performance and care quality.

who use action strategies in terms of selective optimization


with compensation are better able to maintain performance under high workload levels.
 Among the three strategies, selection (i.e. to prioritize
goals) and compensation (i.e. to flexibly apply means in
case of hindrances) turned out to be the most effective.

How should the findings be used to influence policy/


practice/research/education?
 Nurses should be acquainted with the concept of selective
optimization with compensation and its potential benefits
for managing high workload levels.
 Future studies should incorporate specific nursing task
characteristics, individual characteristics of nurses and differentiated performance measures to further discover the
complex interrelation between selective optimization with
compensation and performance.

Introduction
Complaints about high levels of workload in the nursing
profession, in terms of the amount of direct and indirect
patient care activity required to carry out the nursing function (Morris et al. 2007, p. 468), have considerably
increased over the last decade (Myny et al. 2011). Nurses
are especially exposed to highly complex demands due to
the unpredictability of events, missing information, unreliable access to resources (Ebright et al. 2003) and a high frequency of interruptions and multitasking demands (Kalisch
& Abersold 2010). High nursing workload, in turn, is considered to be a major threat to performance (and care)
quality (e.g. Carayon & Gurses 2005, Holden et al. 2011,
Van Bogaert et al. 2013). A further typical consequence of
higher levels of workload and frequent interruptions is a
construct known as forgetting of intentions (Einstein et al.
2003, Baethge & Rigotti 2013). Even under optimally
designed work conditions, an increase in nursing workload
2

Background
The purpose of this paper was to investigate whether selective optimization with compensation (SOC; Baltes & Baltes
1990) constitutes an adequate action strategy of nurses both
to maintain quality of performance and to minimize forgetting of intentions under high workload levels. In recent
years, SOC has become a powerful model which has been
used to explain action at work (Baltes & Dickson 2001,
Baltes & Finkelstein 2011, Baltes et al. 2012, Truxillo et al.
2012). From the perspective of action regulation theory
(Frese & Zapf 1994, Hacker 2003) and Conservation of
Resources Theory (COR; Hobfoll 1989, 2001, 2002), SOC
is a psychological construct that is characterized as involving goal-related behaviour that enables a more adaptive
and efficient use of available mental and physiological
resources, such as cognitive capacities, to improve an individuals health and well-being (Baltes 1997, Freund & Baltes 2002). According to Freund and Baltes (2002), the three
action strategies known as selection, optimization and compensation can be defined as follows: With selection, an individual focuses resources on specific goals as opposed to
distributing resources among multiple goals. Thus, selection
determines the direction and scope of resource allocation
(e.g. a nurse prioritizes the most urgent job tasks in periods
of high workload). Optimization involves the individual
obtaining and constantly improving the means of successfully pursuing a selected goal and refers to the quality and
the tenacity of intra-individual resource allocation (e.g. a
nurse persistently attempts to meet the requirements of the
prioritized job task until it is successfully accomplished).
Compensation also refers to the means and processes of
goal attainment. However, it specifically involves the acquisition and application of alternative means of achieving a
selected goal despite intra-individual or external hindrances.
Thus, compensation specifically refers to the flexibility of
intra-individual resource allocation (e.g. a nurse asks
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colleagues for help in case problems arise during task


accomplishment). In sum, the SOC model implicates that
individuals use their intra-individual resources more efficiently and adaptively when they focus on fewer, but
nonetheless important, goals, pursue these goals in an optimized way and flexibly apply compensatory means (Baltes
1997).
Taking this resources perspective, we hypothesize that
SOC in nursing helps in dealing with high levels of workload. As individuals mental and physiological resources are
limited and as permanent work at the maximum-load level
is known to jeopardize not only performance, but also
well-being, effective resource allocation especially the prioritization of goals plays a major role in the relation of
workload and human performance (Hockey 1997). Accordingly, a growing body of research in the field of nursing
points out that SOC is a meaningful concept for explaining
efficient and adaptive resource allocation in terms of maintaining work ability (M
uller et al. 2012, 2013, Weigl et al.
2013, Riedel et al. 2015, von Bonsdorff et al. 2014). Furthermore, outside the nursing profession, the use of SOC at
work has been generally shown to be specifically favourable to job performance (Abraham & Hansson 1995, Bajor
& Baltes 2003, Yeung & Fung 2009, Demerouti et al.
2014). However, the SOC performance interrelation has
turned out to be affected by task characteristics and performance indicators (see Yeung & Fung 2009, Demerouti
et al. 2014). Moreover, SOC, like any other behaviour, is
shaped by environmental resources and constraints (Riediger et al. 2006). Accordingly, one study by M
uller et al.
(2013) has shown that nurses apply specific strategies of
SOC that have a positive effect on workability over and
above general SOC strategies. In this mixed-method study,
17 nurses reported in semi-structured interviews that they
use SOC strategies mainly to cope with high job demands;
a subsequential cross-sectional survey with 438 nurses
showed that these strategies are positively related to work
ability. The positive relationship was stronger for older
nurses.
To inform those in the nursing practice better, there is a
need for research that explicitly tests for the interrelation
between workload and SOC on performance. This study
contributes to existing empirical evidence in several ways.
First, by using a diary approach, we capture daily fluctuations in the workload of nurses and test for relationships
that happen in one persons experience (within-person
design). Diary studies are a method to collect data at the
daily level or even several times a day (Ohly et al. 2010, p.
79). Cross-sectional studies, as the most prevalent research
paradigm in quantitative research, follow a between-person
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Nursing performance under high workload

approach (i.e. they look at differences between persons to


identify these relationships). However, workload likely fluctuates from day to day and so gathering information from
one source who experiences these fluctuations was important in our research design. With a diary study, we do not
compare groups of respondents, but we can make statements on (temporal) relationships of variables in a person.
Thus, the interpretation of our proposed main effects would
be: On days with a higher than average workload, nurses
will experience decreased levels of performance quality.
This enables a more valid assessment, with close temporal
proximity, of workload in the natural work setting of
nurses. Second, we expand the evidence of the usefulness of
a context-specific measure of SOC strategies adapted for
the nursing profession (M
uller et al. 2013), especially in
terms of effects on performance quality and forgetting of
intentions.

The study
Aim
Our diary study investigates the interactive effects of workload and SOC on performance quality and forgetting of
intentions in nurses. We hypothesize that: (1) Workload is
(a) negatively related to performance quality; and (b) positively related to forgetting of intentions in nursing; and (2)
SOC moderates (a) the negative relation between workload
and performance quality; and (b) the positive relation
between workload and forgetting of intentions in nursing,
such that these relations are weaker in nurses with high
SOC use compared with nurses with low SOC use.

Design
This diary study (cf. Ohly et al. 2010) had a non-experimental prospective design. It combined daily self-reports of
workload and performance (repeated measures over five
consecutive workdays for each person) with one overall
measure of SOC strategies. This design allowed us to capture the short-term dynamics between workload and performance on a day level (see Hypothesis 1). Moreover, it
enables the examination of whether the overall personal
level of SOC strategies affects these daily associations (see
Hypothesis 2). We contacted 56 nursing directors in German hospitals and out of these, 10 agreed to take part in
the study. In each hospital, a group of nurses was recruited
who voluntarily participated in the study and could arrange
to have five morning shifts in a row. We decided to sample
only morning shifts because workload can be expected to
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A. Baethge et al.

vary across days, especially during the morning shift. In


addition, we only sampled morning shifts to keep working
conditions comparable within and across participants and
to rule out potential effects of shift changes on the relationships under study.
Prior to the diary assessment, the participants filled in a
paper and pencil questionnaire that asked for sociodemographic background variables and for the general use of
SOC in their daily work. We organized meetings with the
participants where we explained the use of the handheld
computers (ETEN glofiish X610/50; software: IzyBuilder
Research), which were used for the diary assessment.
Over five consecutive workdays (morning shifts), selfreport data on workload was collected on three occasions
during the shift. The handheld computer was programmed
to give a signal at three pseudo-randomized time points
to capture the beginning, middle and end of the shift. We
set the parameters so that at least 1 hour had to pass
between the signals. Also, participants were instructed to
fill in the questionnaire in half an hour of the signal. The
dependent variables performance quality and forgetting of
intentions were measured in the evening. Participants were
instructed to fill in the evening questionnaire before going
to bed.

Sample/participants
The general survey and the diary survey were completed by
136 nurses (73% males) from 10 German hospitals. Mean
age was 4081 years (SD 1159; range = 2161 years) and
mean organizational tenure was 1833 years (SD 1225;
range = 01043 years. Most of the participants (813%)
were employed full time and in a permanent position
(821%). They worked in inpatient wards in the following
specialties: internal medicine (244%), surgery (179%),
neurology (146%), paediatrics (73%), intensive care
(65%), gynaecology (57%), ENT (33%), dermatology
(16%), geropsychiatry (08%), urology (08%), emergency
ward (08%) and others (81%).

Data collection
We collected the data using the following German-language
instruments.
SOC
To measure selection, optimization and compensation, we
used a German instrument developed for the nursing context by M
uller et al. (2013).

Workload
We used the German version of the NASA-TLX scale (Hart
& Staveland 1988), with seven items. An example item is:
How fast was the pace at which you had to accomplish
your tasks during the last half hour? Answers were given
on a 20-point scroll bar ranging from 1 (very low)-20 (very
high).
Performance quality
To measure subjective satisfaction with ones own performance quality, we adapted one item from Abramis (1994):
Today, I satisfied the personal expectations I have of my
work. Respondents had to indicate the extent to which they
agreed with the statement using a five-point Likert-type
scale, ranging from 1 (strongly disagree)-5 (strongly agree).
Forgetting of intentions
To measure forgetting of intentions in the evening (before
going to bed), we asked our respondents: Today, did you
forget to complete a task you had started or planned to
do? Answers were coded 0 (no) and 1 (yes).

Ethical considerations
According to local regulations, no formal ethical scrutiny
was undertaken. Participation in the study was voluntary
and all participants provided their informed consent to take
part in the study. The collected data were handled in a way
to ensure anonymity of participants. All organizations and
participants in the study received a report on the outcomes
of the study.

Data analyses
We conducted multilevel analyses because the daily assessments were nested within persons and were thus not independent from each other (Ohly et al. 2010). We used the
software package R 3.1.1 (R Core Team, 2014). Centring
the day-level variable workload at the person mean allowed
for the removal of between-person variance from this variable. This eliminated the role of stable differences in
explaining a participants day levels of the perceived stressor workload (Ohly et al. 2010). The moderator variable
SOC, which was assessed on level 2, was centred at the
grand mean. We allowed random slopes and tested them
against simple slope models. As the random slope models
did not have a significantly better fit, we chose the simple
slope model as grounds of Occams razor (Nezlek et al.
2006).

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To test whether our data needed the use of multilevel


modelling, we calculated the intra-class correlations (ICC)
on the basis of the intercept-only models. The ICC
explains how much of the variance can be attributed to
the different levels of analyses. The between-person variance was 387% for performance quality and 685% for
forgetting of intentions. The within-person variance (variance from 1 day to another) was 613% for performance
quality and 315% for forgetting of intentions. These
results indicated that there was sufficient variance attributable to both between- and within-persons in day-level
performance quality and forgetting of intentions to support the use of multilevel modelling in our study. To test
the hypotheses, we first tested the control variable age,
then we added the main variable workload, followed by
SOC. In the last step, we added the two-way interaction
of workload and SOC.

Nursing performance under high workload

validity of both variables with some typical stressors in the


nursing occupation: multitasking, interruptions and time
pressure (Kalisch & Abersold 2010). If these demands are
high, nurses should have less time to complete their tasks
and the concentration demand should be high (Baethge &
Rigotti 2013). Thus, resources are spent that are needed to
complete high quality tasks and to keep on course during
the task, especially regarding those tasks which should be
done next. We found statistically significant negative relationships between the three stressors and performance quality (multitasking: B = 028, P < 0001; interruption:
B = 001,
P < 005;
time
pressure:
B = 015,
P < 0001). In addition, forgetting of intentions also had a
statistically significant positive relationship with multitasking and interruptions (multitasking: B = 092, P < 001;
interruption: B = 008, P < 001).

Results
Validity and reliability
SOC
The study by M
uller et al. (2013) demonstrated the validity
of the scale in terms of substantial positive correlations
with the established general SOC-measure by Baltes et al.
(1999). Moreover, previous studies showed positive associations with the work ability of nurses (M
uller et al. 2012)
and predictive effects on the well-being of nurses in a 6month time span (M
uller et al. 2013). Each subscale consists of three items (e.g. I concentrate on the most important tasks to do my job well for selection; I do exercises
to accomplish the physical demands in nursing for optimization; I ask for help to accomplish heavy physical tasks
for compensation). Answers were given on a five-point
scale, ranging from 1 (no, not all)-5 (yes, exactly). Cronbachs alpha was 077 for the whole scale and 058 (S),
063 (O) and 077 (C) for the subscales.
Workload
Cronbachs alpha in our sample ranged from 078-086 in
the three shift occasions of the 5 days (shift 1: 078-085;
shift 2: 082-086; shift 3: 084-086). The NASA-TLX scale
(Hart & Staveland 1988) has been shown to have good
concurrent validity with other instruments measuring workload (Rubio et al. 2004). Furthermore, it has been used in
other nursing studies (Lopez et al. 2010) establishing, for
instance, a positive relationship with sleepiness (Geiger
Brown et al. 2014).
As performance quality and forgetting of intentions were
one-item measures, no Cronbachs alphas for these scales
can be calculated. Nonetheless, we tested the convergent
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Means, standard deviations and intercorrelations of the


study variables are shown in Table 1.

Workload: main effects on performance quality and


forgetting of intentions
To test the proposed main effects of workload, we estimated multilevel regressions with the level 1 variable workload to predict the dependent variables performance quality
and forgetting of intentions (logistic model), while controlling for the level 2 variable age. Results of these analyses
are presented in Tables 2 and 3. The two direct effect
hypotheses were supported (see Model 2 in Tables 2 and
3). A high workload was significantly negatively related to
performance quality (Hypothesis 1a) and positively related
to forgetting of intentions (Hypothesis 1b). There was no
(or just a marginally) statistically significant relationship of
age with the two outcomes.

Moderating effect of SOC


To test the two-way interactions between workload and the
two outcomes, we included SOC and the interaction
between SOC and workload. The two-way interaction
hypotheses (2a and 2b) proposing SOC as a moderator
between the independent variable workload and the dependent variables performance quality and forgetting of intentions were supported (see Model 4 in Tables 2 and 3).
The graphs (Figures 1 and 2) show that both interaction
effects were in the assumed direction; that is, there is a
weaker association between workload and both indicators
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A. Baethge et al.

Table 1 Means, standard deviations and zero-order correlations of all study variables.

1
2
3
4
5
6
7
8

Variable

SD

SD

Age
SOC (total)
Selection
Optimization
Compensation
Workload
Performance
Quality
Forgetting

4098
384
413
361
377
782
389

1155
055
054
073
084
242
067

783
392

284
088

012
016
004
010
022*
014

013

022

013

033

011

066***
080***
085***
012
035***

032***
037***
017
038***

029***

023**

049***
008
025**

007
023**

027**

021*

034***
039***
027**

022***
024***

037***

Correlations below the diagonal are person-level correlations (N = 129-136). Correlations above the diagonal are day-level correlations
(n = 593-631). Day-level correlations can only be estimated with variables assessed at the day level.
*P 005; **P 001; ***P 0001.

Means and standard deviations at the person level.

Means and standard deviations at the day level.


SOC, selection, optimization, compensation.

Table 2 Estimates for multilevel models predicting performance quality.


Performance quality

Parameter
Intercept
Level 1
Workload
Level 2
Age
SOC
Interaction
Workload 9 SOC
2 * log
Diff-2 * log
d.f.

Model 1
B (SE)
390 (006)***

001 (000)+

51531

Model 2
B (SE)

Model 3
B (SE)

Model 4
B (SE)

389 (006)***

389 (005)***

389 (005)***

008 (002)***

008 (002)***

008 (002)***

001 (000)+

001 (000)
044 (010)***

001 (000)
044 (010)***

40587
943**
1

39310
1277***
1

008 (003)*
38781
529*
1

Level 2: N = 129-131. Level 1: n = 566-571. The scores of the Level 1 variables were centred at the individuals means to eliminate
between-individual variance. The scores of the Level 2 variables were grand-mean centred.
+
P 01; *P 005; **P 001; ***P 0001.

of job performance for nurses who report a high level of


use of SOC (+1 SD) compared with nurses who report a low
level of use ( 1 SD).

Additional analyses of the subscales of SOC


In subsequent analyses, we tested which subscales of SOC
(selection, optimization and/or compensation) acted as moderators in the relationship between workload and performance quality or forgetting of intentions. For that purpose,
we analysed multilevel models with the level 1 predictor
workload, one of the three SOC subscales as a level 2 moderator and the level 1 outcomes performance quality and

forgetting of intentions (using Bonferoni-corrected alpha


levels). Again, we controlled for age in all models (Tables 4
and 5). There were significant interactions among workload
and selection in explaining performance quality and forgetting of intentions and there was a significant interaction
among workload and compensation in explaining performance quality. The interaction among workload and compensation was not significant for forgetting of intentions.
Furthermore, there were no significant interactions among
workload and optimization in explaining performance quality or forgetting of intentions. The graphs (Figures 35)
show that all of the reported subscale interaction effects had
the same pattern as their total scale counterparts.

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Nursing performance under high workload

5
Performance quality

45
4
35
3
25
2
Low SOC (1 SD)
High SOC (+1 SD)

15
1
Low workload (1 SD)

High workload (+1 SD)

Figure 1 Interaction effect between workload and SOC on performance quality.

1
09
Probability of forgetting

137386
3461***
1
140846

Level 2: N = 131-133. Level 1: n = 571-587. The scores of the Level 1 variables were centred at the individuals means to eliminate between-individual variance. The scores of the
Level 2 variables were grand-mean centred.
+
P 01; *P 005; **P 001; ***P 0001.
Coef., unstandardized regression coefficient; OR, odds ratio; CI, confidence interval.

050-097
132909
647*
1
069
036 (017)*
133555
3830***
1

099-107
016-069
103
033
099-107
015-062
102
102
002 (002)

099-106

002 (002)

099-106

003 (002)
118 (036)**

103
031

003 (002)
111 (037)**

099-107
122
105-154
127
024 (010)*

105-154

024 (010)*

128

020 (010)+

005-011
007
267 (021)***
005-011
007
264 (021)***
004-010
007
273 (022)***
005-010
007
268 (021)***

OR
Parameter

Intercept
Level 1
Workload
Level 2
Age
SOC
Interaction
W 9 SOC
2 * log
Diff-2 * log
d.f.

Coef. (SE)
Coef. (SE)
95% CI
OR
Coef. (SE)
Coef. (SE)

95% CI

Model 2
Model 1

Forgetting of intentions

Table 3 Estimates for multilevel logistic regression models predicting forgetting of intentions.

Model 3

OR

95% CI

Model 4

OR

95% CI

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08
07
06
05
04
03
02
01
0
Low workload (1 SD)

Low SOC
(1 SD)
High SOC
(+1 SD)
High workload (+1 SD)

Figure 2 Interaction effect between workload and SOC on forgetting of intentions.

Discussion
Our study demonstrates that SOC is an adequate, individualized action strategy for nurses who want to optimize their
job performance under high workload levels. The use of
SOC emphasizes the efficient use of intra-individual
resources at hand for the most important work goals and
the optimized pursuit of these goals, while considering possible compensatory means. As such, SOC should not be
mistaken with a downward adjustment of task goals under
excessive workload (such as reducing the accuracy, paying
less attention to subsidiary tasks, e.g. Hockey 1997). Nevertheless, SOC is in contrast to the mere increase in overall
effort to keep up performance during high workload levels.
Putting more energy and (compensatory) effort into a task
could increase performance outcomes in the short run, but
it would also deplete resources, leading to fatigue and, in
turn, higher levels of strain (cf., Zijlstra et al. 1999, Mark
et al. 2008, Baethge et al. 2015). Instead of working
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Table 4 Additional (post-hoc) analyses of the three subscales of SOC (Performance Quality).
Outcome
Moderator
Parameter
Intercept
Level 1
Workload
Level 2
Age
Moderator
Interaction
Workload 9 Moderator

Performance quality
Selection
B (SE)

Optimization
B (SE)

Compensation
B (SE)

388 (005)***

388 (006)***

389 (005)***

007 (002)***

007 (002)**

008 (002)***

000 (000)
050 (010)***

001 (000)
022 (008)*

001 (000)
019 (007)*

008 (003)*

003 (003)

006 (002)*

Level 2: N = 129-131. Level 1: n = 566-571. The scores of the Level 1 variables were centred at the individuals means to eliminate
between-individual variance. The scores of the Level 2 variables were grand-mean centred.
The alpha levels were Bonferoni-corrected (divided by 3).
*P 0017; **P 0003; ***P 00003.

harder, SOC is a way of working smarter. Our study corroborates previous findings of the benefits of SOC for job
performance (Abraham & Hansson 1995, Bajor & Baltes
2003, Yeung & Fung 2009, Demerouti et al. 2014) and
contributes to the growing body of research showing that
the use of SOC buffers detrimental effects of stressful or
difficult work conditions (Yeung & Fung 2009, Zacher &
Frese 2011, Schmitt et al. 2012). Furthermore, the reported
results extend the validity of these findings to the nursing
profession.
Like other studies, we observed differential effects of the
three SOC sub-dimensions on performance. In line with
previous research (Abraham & Hansson 1995, Bajor &
Baltes 2003, Yeung & Fung 2009), our findings indicate
that selection strategies are particularly conducive to performance. This finding highlights the benefits of the prioritization of goals in stressful work situations (Hockey
1997). Especially in the nursing profession, it is important
to quickly decide which are the most urgent of the tasks at
hand (Lake et al. 2009). Otherwise, a special characteristic
or difficulty of the nursing profession is that most of the
tasks have to be done during one shift. That is, they cannot
be postponed to the next day. Thus, selection does not necessarily mean that non-relevant tasks are skipped. On the
contrary, selection could mean that tasks are (re-)scheduled
and that the amount of resources (e.g. time, effort) is allocated to different tasks. It is possible to spend more time
on tasks that are done first rather than on tasks that have
to be done shortly before the shift ends. Another characteristic of the nursing profession is the definite end of the
workday, or the handover. Tasks have to be performed up
to this deadline. It is unusual for nurses to finish tasks after
8

their shift ends. Thus, selection in terms of prioritizing is of


special importance in the healthcare setting. However,
recent studies have suggested that the strength and direction of the interrelation between SOC sub-dimensions and
performance might be affected by moderating factors and
the specific performance dimension under consideration: In
one recent study, Demerouti et al. (2014) observed that
selection strategies enhanced the negative impact of burnout on performance during a secondary job task and additionally, that of all the SOC strategies, compensation was
the most successful strategy in buffering the negative effects
of burnout on performance. Demerouti et al. concluded
that in line with the Conservation of Resources Theory
(COR, Hobfoll 1989, 2001, 2002), individuals with
impaired resources strive to protect themselves from further
loss of resources by focusing their energy on the most
important core tasks and by disregarding secondary tasks.
Other studies especially underline the importance of
employees age on the SOCperformance relationship:
Abraham and Hansson (1995) observed that selection and
optimization are particularly favourable to performance
maintenance in older employees. Accordingly, Yeung and
Fung (2009) observed in a diary study among sales workers
that the contribution of selection to momentary task performance was greatest among older workers with highly
difficult tasks. Again, from the perspective of COR Theory
(Hobfoll 1989, 2001, 2002), SOC seems to help older
employees with potentially limited resources to manage job
situations that put high demands on available resources.
However, another finding of Yeung and Fung (2009) stated
that considering more global levels of performance
SOC strategies in difficult tasks increased performance only
2015 John Wiley & Sons Ltd

JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH QUANTITATIVE

Nursing performance under high workload

Table 5 Additional (post-hoc) analyses of the three subscales of SOC (Forgetting of Intentions).
Forgetting of intentions

Outcome

Selection

Moderator
Parameter

Optimization

Coef. (SE)

Intercept
Level 1
Workload
Level 2
Age
Moderator
Interaction
W 9 Moderator

OR

95% CI

276 (023)***

006

004-010

018 (011)

119

003 (002)
105 (042)*
054 (019)*

Compensation

Coef. (SE)

OR

95% CI

269 (022)***

007

004-010

097-147

021 (002)

123

103
035

099-107
015-079

002 (002)
074 (029)*

058

040-085

020 (012)

Coef. (SE)

OR

95% CI

267 (021)***

007

005-011

101-151

023 (010)+

125

103-153

102
047

099-106
027-085

003 (002)
050 (025)

103
060

099-106
037-098

082

064-104

015 (011)

086

069-107

Level 2: N = 129-131. Level 1: n = 566-571. The scores of the Level 1 variables were centred at the individuals means to eliminate
between-individual variance. The scores of the Level 2 variables were grand-mean centred.
The alpha levels were Bonferoni-corrected (divided by 3).
+
P 003; *P 0017; ***P 00003.
Coef., unstandardized regression coefficient; OR, odds ratio; CI, confidence interval.

1
09

Performance

4
35
3
25
2
Low selection (1 SD)
High selection (+1 SD)

15
1
Low workload (1 SD)

High workload (+1 SD)

Probability of forgetting

5
45

08
07
06
05
04
03
02
01
0
Low workload (1 SD)

Low
selection
(1 SD)
High
selection
(+1 SD)
High workload (+1 SD)

Figure 3 Interaction effect between workload and selection on


Figure 5 Interaction effect between workload and selection on

performance quality.

forgetting of intentions.

5
4.5
Performance

4
3.5
3
2.5
2

Low compensation (1 SD)

1.5

High compensation (+1 SD)

1
Low workload (1 SD)

High workload (+1 SD)

Figure 4 Interaction effect between workload and compensation


on performance quality.

in younger employees, but not in older employees. The


authors concluded that in the long run, older employees
might need other strategies besides SOC to handle difficult
tasks successfully.
2015 John Wiley & Sons Ltd

Thus, although available studies, in general, have agreed


that SOC is beneficial to job performance, future studies
that explicitly incorporate specific task characteristics, individual characteristics of the employee and different performance measures are still needed to further discover the
complex SOCperformance interrelation. Considerations of
COR Theory (Hobfoll 1989, 2001, 2002) might provide a
promising avenue to start such endeavours.

Limitations and strengths


Like all studies, this one does not come without limitations.
First, a convenience sample was used, possibly limiting generalizability. However, nurses from 10 different hospitals and a
broad range of disciplines participated in the study. Second,
our study exclusively used self-report data. Thus, common
9

A. Baethge et al.

method variance might lead to an inflation of observed associations (Podsakoff et al. 2012). By using a within-person
design and a multilevel framework (centring focal variables
by the person mean), we were able to rule out between-person differences as having influenced the results. Still, future
studies may opt to assess both workload and performance
outcomes by means other than self-report, such as workplace
observations, supervisor ratings or objective performance
indicators. Third, the assessment of workload during the shift
might be perceived as an additional stressor. The time to
respond to the questions during the shift averaged less than
three minutes. Given the high complexity of demands in nursing, we believe it is unlikely that it was our questionnaire that
substantially increased the level of workload. Fourth, the outcomes were assessed using 1-item scales and although more
item scales would have a higher reliability, it is the common
practice in diary designs to use such (short) scales to keep
intrusive effects of the study low and the compliance of participants high (Ohly et al. 2010). Fifth, the Cronbachs alpha
of the SOC subscales selection and optimization is quite low.
Similar findings were reported in several other studies on the
SOC model (e.g. Freund & Baltes 2002, Riedel et al. 2015).
This might reflect the fact that SOC captures a multifaceted
phenomenon that usually is accompanied by decreased internal consistencies. The results of the SOC subscales, therefore,
have to be interpreted with caution. A replication with a
more reliable assessment of the subscales is needed. In the
case of selection, we have already begun a discussion on the
presumably diverse nature of this construct. What is still
needed is an assessment of the different facets of selection in
different occupations. Nevertheless, as the Cronbachs alpha
of the total SOC scale is acceptable, our overall finding that
SOC is conducive to the job performance of nurses under
high workload levels is reliable. Finally, even with a diary
study conducted over five consecutive workdays, we cannot
make any causal statement about the relationship of studied
variables.

the use of SOC in nurses (M


uller et al. 2012) and aggravates its effects (Weigl et al. 2013). Moreover, there are
indications that the use of SOC in nurses is related to supportive and just leadership behaviour (von Bonsdorff et al.
2014). Thus, healthcare organizations should provide
nurses with enough security to make their own decisions
(Kalisch & Abersold 2006). Promising organizational-level
approaches include both the option to eliminate environmental sources of excessive workload in nursing (e.g. Bourbonnais et al. 2006, 2011) and to increase environmental
job resources, such as autonomy, that buffer the negative
effects of workload on performance in nursing (e.g. Gillet
et al. 2013). Effective individual strategies in nurses are
important, but it is important to stress that they go hand in
hand with a supportive work environment. Therefore, how
to deal with high levels of nursing workload should not be
left exclusively to the individual nurse.

Funding
This research was supported by the Bundesanstalt f
ur
Arbeitsschutz und Arbeitsmedizin.

Conflict of interest
No conflict of interest has been declared by the authors.

Author contributions
All authors have agreed on the final version and meet at
least one of the following criteria [recommended by the
ICMJE (http://www.icmje.org/recommendations/)]:

substantial contributions to conception and design,


acquisition of data, or analysis and interpretation of
data;
drafting the article or revising it critically for important
intellectual content.

Conclusion
Our findings are in line with calls for empowering nurses
individual decision-making due to the fact that they are the
experts in how care should be delivered (Kalisch & Abersold 2006). In that vein, nurses might already be acquainted
with the SOC model and its potential benefits to managing
high workload levels. Nevertheless, individual strategies,
such as SOC, have to be safeguarded by a supportive work
environment: Research has indicated that job control in
terms of autonomy and discretion to schedule work and
make decisions (Morgeson & Humphrey 2006) facilitates
10

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