It has been shown that a recently defined stressor related to improper use of work time, termed ‘illegitimate tasks’ [
1,
2], is related to stress and well-being at work [
3‐
7]. Findings from both Europe and the US have been published [
1,
4,
8,
9], but findings on illegitimate tasks and their relationship with stress outcomes need to be validated in samples from different cultures and occupational groups [
1,
2,
10]. In addition, because organisations and employees aim to minimise the frequency of illegitimate tasks, there is a need to explore possible antecedents of illegitimate tasks [
4]. Efficiency has for many years been a key policy goal in many Western countries [
11] and increased knowledge about the extent and content of the illegitimate tasks undertaken by physicians would help to improve the efficiency of health services. There is evidence that there has been an increase in the proportion of work time that physicians spend on non-core tasks [
12], raising concern that physicians’ time is not being used appropriately. This inappropriate use of physicians’ work time can be associated with performance of illegitimate tasks. To our knowledge there has not yet been any systematic investigation of the proportion of physicians’ workload that is made up of unreasonable illegitimate tasks. The aim of this study was to investigate the prevalence of unreasonable illegitimate tasks, associated psychosocial work environment factors and one health-related outcome amongst physicians working in a hospital setting.
Theoretical background
Illegitimate tasks, defined as work tasks that are not related to one’s core occupation or that one perceives as inappropriate and a waste of time, are an emerging issue in occupational stress research [
2,
7]. If an employee perceives that a work task should have been carried it out by others, or if it violates norms about expected work tasks or challenges his or her professional identity then it is considered illegitimate [
1,
2]. The concept of illegitimate tasks is derived from the stress-as-offense-to-self (SOS) theoretical framework, which posits that being assigned an illegitimate task may trigger stress reactions [
1], based on Lazarus’s [
13] assumption that stress is related to threats to important goals. There are two types of illegitimate tasks: unnecessary and unreasonable [
1,
2,
7]. Unnecessary illegitimate tasks are defined as tasks that are perceived as a waste of time and need not be done by anyone, and tasks that could have been avoided or carried out with less effort if things were organised more efficiently [
2], e.g. transferring patient data manually because two technological systems are incompatible. Unreasonable illegitimate tasks are tasks that are outside one’s occupational role and conflict with specific aspects of one’s role or occupational status [
2], e.g. physicians asked to transporting a bedbound patient are likely to criticise the organisation for taking them away from their core task, which is medical treatment, whereas a hospital orderly would see the same task as part of his or her daily work [
4]. At the theoretical level it has been argued that unreasonable and unnecessary illegitimate tasks should be treated as separate constructs [
8]. In this study we investigate reports of unreasonable illegitimate tasks. Unreasonable illegitimate tasks are considered the main facet of illegitimate task and deserve research attention because of their association with work engagement and time pressure [
14].
Physicians can be described as cost-generating professionals because they have high salaries and demand additional treatment resources [
15], so it is inefficient to have physicians carrying out tasks that could be performed by others and it has been suggested that research into the medical profession’s experience of illegitimate tasks is needed [
3]. Physicians’ perception of illegitimate tasks can depend on a variety of factors within their work context [
16]. Ahmned, Eatough, and Ford [
17] found national variations in illegitimate task burden and outcomes of undertaking illegitimate tasks. This study investigated physicians at a Norwegian university hospital. As part of the public health care system, hospitals are owned by the government, run by regional health authorities and publicly funded as part of the national budget. Part of hospitals’ income is activity-based, but physicians are permanent employees with fixed salaries. General practitioners are self-employed, but publicly financed, partly on a fee-for-service basis. In addition Norway has a strong Work Environment Act and strong employment protection legislation. There is also a relatively low power distance between employees and employers in Norway [
18]. Power distance is the degree to which less powerful members of a society are comfortable with the unequal distribution of power and recognise it as legitimate [
18]. In Norway, as in many other countries, there has been a change in task management and an increase in the amount of work time spent by employees on additional tasks and administration. Accordingly, it is possible that illegitimate tasks are experienced as a threat to time spent on core tasks.
Health care workers, including physicians, report spending increased amounts of time on meetings, administration, measurement and reporting rather than working with patients [
3,
12,
19]. The growing number of administrative tasks diverts time and attention away from more clinically important activities [
19]. These administrative tasks are not unnecessary, but are likely to fall - to some extent - outside of the range of tasks physicians consider part of their professional role. Hence there is a need to explore how administrative burden relates to reports of illegitimate tasks. A better understanding of illegitimate tasks should make it possible to make better decisions about task assignment [
7] and task management. Ahmed et al. [
17] highlighted the risk that as a result of increased focus on the economic growth, employees will find themselves assigned more tasks, including administrative tasks, that fall outside their formal job role. More knowledge of the correlates of illegitimate tasks should enable organisations to reduce their number [
10] or find ways to manage them in a more resource-efficient manner.
As illegitimate tasks have been shown to act as a job stressor it is important to investigate how they affect physicians’ health and well-being [
4,
7,
20]. Previous research has shown that illegitimate tasks are negatively related to job satisfaction [
4,
6] and positively related to counterproductive behaviour [
2] and stress reactions among employees [
21]. One study found that participants who experience a high burden of illegitimate tasks had higher levels of the stress hormone cortisol than peers dealing with fewer illegitimate tasks [
22]. In addition, illegitimate tasks have been shown to reduce sleep quality [
23], and have been prospectively associated with lower mental health [
5] as well as being correlated with negative affect and low self-esteem at the end of the working day [
8]. Illegitimate tasks have also been found to be strongly associated with strain outcomes, such as feelings of resentment towards one’s organisation and irritability, over a period of 2 months [
7], and have been related to turnover intention [
10]. Overall, previous research indicates that illegitimate tasks have negative consequences for both individuals and organisations, but none of these studies has looked at the experiences of physicians. We argue that in order to improve our understanding of unreasonable illegitimate tasks it is important to study the phenomenon in a specific profession, as illegitimate tasks are a specific, task-related stressor that constitutes a threat to one’s professional identity [
7,
9].
The SOS theoretical framework implies that being expected to undertake illegitimate tasks can increase the risk of poor health amongst physicians. Performing illegitimate tasks requires emotional and physical effort and may induce symptoms of strain [
7]. Cognitive, affective and physical strain may result in exhaustion [
24], and exhaustion has been shown to correlate with illegitimate tasks [
3,
7,
25]. Exhaustion has also been shown to have a reciprocal relationship with sickness presenteeism [
26], defined as attending work when ill [
27]. Amongst physicians strain and ill health often manifest as sickness presenteeism [
28‐
30], which has been shown to be prevalent among physicians [
28,
30,
31]. Physicians often go into work when they are ill, because of their high work load, the lack of a replacement, responsibility and their crucial role in hospitals’ main task, which is medical treatment [
28,
30,
32]. Illegitimate tasks can be regarded as stressors that can contribute to strain and a variety of negative health outcomes [
21]. The job demands-resources model [
33,
34] provides a theoretical framework which explains why unreasonable illegitimate tasks may be associated with sickness presenteeism. Unreasonable illegitimate tasks may be considered job demands, as it requires effort to carry them out and they impose demands on individuals who do so [
7]. It is possible that in a bid to cope with the pressure of unreasonable illegitimate tasks, physicians use sickness presence as a strategy for coping with their high workload and so the relationship between unreasonable illegitimate tasks and sickness presenteeism should be investigated [
3].
A high prevalence of tasks perceived as illegitimate can imply that an organisation would benefit from allocating resources differently. As previous research on illegitimate tasks has reported that they have consequences for both individuals and organisations, there is a need for studies of the prevalence of illegitimate tasks in different professions [
2,
4,
7]. Although there have been advances in research on illegitimate tasks studies of the relationships between illegitimate tasks, workplace correlates and health-related outcomes are scarce [
4,
9]. A job characteristic associated with illegitimate tasks, especially unreasonable illegitimate tasks, is role conflict, defined as lack of congruent expectations and demands from other people in the workplace [
35,
36]. As the concepts of role conflict and illegitimate tasks are highly related but distinguishable from each other, it is important to control for role conflict in research on illegitimate tasks [
1,
2,
7]. In addition, performance of work tasks that are outside their core role or job definition has been associated with stress and ill health in physicians [
19,
37]. Investigating the relationship between unreasonable illegitimate tasks and health outcomes is important, as physicians’ ill health can indirectly or directly affect the quality of health care and patient safety [
38‐
40].
Based on the theoretical framework and review of previous findings, the aim of this study was threefold: 1. To investigate what proportion of working time hospital physicians think they spend on unreasonable illegitimate tasks and how this varies with clinical position, gender, age and reported administrative workload. 2. To analyse the relationship between unreasonable illegitimate tasks and reported administrative work amongst physicians whilst controlling for variance in role conflict, gender and age. 3. To describe the relationship between unreasonable illegitimate tasks and sickness presenteeism in physicians after controlling for variance in age, gender, role conflict, control over work pace, exhaustion and administrative tasks.