Healthcare faces constant changes due to technological and medical innovations that aim to improve the quality, efficiency or safety of care [1, 2]. The factors contributing to or hindering the implementation of these innovations have been widely investigated, showing –among other things– that the involvement of staff is essential for the success of these innovations [1, 3, 4]. However, one largely under-investigated area within and outside healthcare is how these innovations impact workers in terms of their work motivation and the way they experience their work [2, 3, 5–7].
The lack of knowledge about the consequences of innovations for healthcare workers is problematic because work motivation and work characteristics are important predictors of performance and wellbeing [8, 9]. More specifically, autonomous forms of motivation among healthcare workers have been associated with higher quality and safety of care, and with lower susceptibility for burnout [10, 11]. Furthermore, healthcare workers’ motivation and characteristics of the work environment affect the extent to which healthcare workers proactively learn from positive and adverse incidents and speak up in the face of threats to patient safety, which is important for continuous quality improvement and organizational learning within the complex healthcare setting [12, 13].
The aim of the present study, therefore, is to examine the impact of the implementation of technology on the work characteristics and autonomous motivation of healthcare workers. The possible changes in work characteristics and motivation are investigated in an uncontrolled before-and-after study within the context of organizational change. This organizational change entails an innovation that many healthcare institutions have implemented during the past decades, namely an electronic health record (EHR).
The theoretical framework of this study is depicted in Fig. 1. In short, we are curious about the relationship between EHR implementation and healthcare workers’ autonomous work motivation, and we anticipate that two work characteristics, namely, job autonomy and interdependence, mediate this relationship. In addition, we explore the moderating effect of profession on the relationship between EHR implementation and work characteristics.
With this study, we aim to make three contributions to the literature. First, we aim to shed light on the ‘complex array of forces’ [15 p24] that affect the success of technologies, thereby answering calls for research on the impact of technology implementation in the work setting [6, 14]. According to Parker and Grote [15], the forces that affect technology success entail work characteristics, and individual, technological and organizational factors. We aim to contribute to this literature by investigating the effects of EHR implementation on healthcare workers’ work characteristics and their subsequent work motivation. Second, going beyond existing work on technology implementation, which tends to focus on specific groups of workers [5, 14, 15], this study involves four major groups of healthcare workers (physicians, nurses, allied healthcare professionals, and administrative workers) and explores the differences in their reactions to EHR implementation. Finally, we aim to contribute to the literature on the self-determination theory of motivation by following three recommendations to advance the theory, namely, (a) we investigate the relationships between concrete work characteristics and motivation, (b) we do this in the context of technology implementation, and (c) we use a longitudinal (before-and-after) design to do this [6].
Electronic health records
An EHR is a longitudinal digital record of a patient’s health information, such as demographical information, medical history, diagnoses, medications, radiology images, laboratory data, healthcare workers’ notes and other clinically relevant information. Although an EHR could be considered the digital equivalent of the classic paper or computer-based health record of a patient, it differs from the traditional record in important ways. An EHR is an integrated record, containing information from all healthcare workers involved in a patient’s care. This information can be accessed instantly and securely by authorized users [16, 17]. Compared to the traditional records they replace, EHRs increase the availability of information, and support information exchange among health care providers. Additionally, EHRs are often equipped with tools to improve healthcare practice by stimulating healthcare workers’ adherence to guidelines and organizational protocols (for example, through reminders and by blocking access or orders where necessary). Therefore, EHRs have many anticipated functional benefits, such as improved quality, safety, and cost-effectiveness of care, and enhanced clinical decision making [16–18].
In order to harvest these potential functional benefits, clinical and operational changes need to be made [19]. For example, EHRs change and standardize workflows and documentation requirements, shift tasks from one healthcare worker to another, and affect communication during the provision of patient care [16–21]. Thus, implementation of an EHR changes the nature of work for healthcare workers. These changes alter the work characteristics of healthcare workers, which in turn is likely to affect their work motivation [2].
Work motivation
Work motivation is defined as ‘a set of energetic forces that originate both within as well as beyond an individual’s being, to initiate work-related behaviour, and to determine its form, direction, intensity, and duration’ [23 p11]. One widely used theory of motivation and the way it is affected by the (work) environment is the self-determination theory (SDT) [8]. The SDT describes a continuum of various types of motivation. Simply put, this continuum ranges from not wanting to do something (amotivation), through having to do something (controlled or extrinsic motivation), to wanting to do something (autonomous or intrinsic motivation) to [8]. This study focuses on autonomous motivation, as research has shown that an engaged and autonomously motivated healthcare workforce is essential for the delivery of high-quality care [10, 23, 24].
Autonomous work motivation refers to motivation out of reasons stemming from within the employee him- or herself; i.e., it stems from a sense of self-determination. Autonomously motivated employees want to put effort into their work because they find their work enjoyable or interesting (intrinsic motivation), or because the work is in line with their values, personal goals and identity (identified regulation) [8, 25].
Further, the SDT states that motivation becomes more autonomous when workers experience satisfaction of their basic psychological needs for autonomy (the need to feel in control), relatedness (the need to maintain positive relationships with others), and competence (the need to experience a sense of mastery) [8, 9]. Importantly, the SDT states that characteristics of the work hold the potential to boost or thwart autonomous motivation, as they affect the extent to which workers experience satisfaction of their basic psychological needs [8, 9, 26]. Specifically, autonomous motivation is thought to be boosted (vs. thwarted) by work characteristics that support (vs. undermine) employees’ sense of autonomy, competence, and relatedness. Based on this premise, we anticipate that EHR-related changes in work characteristics will be associated with changes in workers’ autonomous motivation [6, 14].
Work characteristics
Work characteristics, here understood as ‘the attributes of the task, job, and social and organizational environment’ [30 p1333], and their consequences for motivation and performance, have been widely investigated [2, 27]. A vast body of research shows that work characteristics, such as job autonomy, clarity about roles, task variety, feedback, team climate, and leadership style, can significantly boost or weaken motivation [2, 27, 28].
Because EHR implementation requires several clinical and operational changes [5, 19], healthcare workers’ work characteristics are likely to be affected by these changes. Subsequently, we will argue that two work characteristics are particularly relevant in case of EHR implementation, namely; job autonomy and interdependence, which are likely to affect satisfaction of the basic psychological needs for autonomy and relatedness. We do not consider the need for competence [8], as we anticipate that feelings of competence are particularly likely to be affected by the quality of training, IT skills and teething troubles of the system [7, 19, 29], which are not the main focus of this study.
Job autonomy. Job autonomy refers to the extent to which the job allows workers freedom to plan their work, to make decisions and to choose work methods [27, 28]. Although the behaviour of healthcare workers is partly directed by protocols and regulations, autonomy is ingrained in the jobs of workers who provide direct patient care (e.g., physicians, nurses or allied healthcare professionals), since their jobs require them to act upon their specific professional knowledge and skills [30, 31]. A high level of autonomy allows flexibility, which supports healthcare workers’ clinical decision making [32]. In addition to supporting the provision of patient care, job autonomy gives healthcare workers a sense of volition at work. This feeling of being self-controlled satisfies their need for autonomy, which contributes to their autonomous motivation [8, 26].
An EHR is likely to affect healthcare workers’ job autonomy, as it enables external control over their clinical decision making and scheduling of work [14, 33]. For example, EHRs often have standardized methods of record keeping, specific built-in workflows that are based on standardized work processes, and may be equipped with decision support tools that guide healthcare workers’ decision-making process for routine tasks. Furthermore, formal control of work procedures may be increased by defining role-based access and role-based permissions (e.g., only physicians rather than other staff members are allowed to order specific tests or medications), and adherence to workflows may be stimulated through reminders or other actions of the system, thereby reducing the extent to which healthcare workers can freely organize their own work tasks [7, 19]. Previous research on EHR implementation found that primary care physicians experienced less autonomy after EHR implementation due to work scheduling interference [33], and nurses participating in a study by Bergey et al. [16 p4] even referred to their hospital’s EHR as ‘a needy baby that has to be answered every time it cries’ to express their workflow-related experiences.
Based on these previous findings, we expect that the introduction of an EHR will decrease healthcare workers’ perceptions of job autonomy (Hypothesis 1a). Since perceptions of job autonomy should be positively related to autonomous motivation (Hypothesis 1b), we anticipate that, taken together, EHR implementation is negatively related to healthcare workers’ autonomous motivation through (i.e., mediated by) their perceived job autonomy (Hypothesis 1c).
Interdependence. The second work characteristic that we consider in this study is interdependence, which refers to the ‘connectedness’ people experience in their job: the extent to which workers depend on others and others depend on them to complete their work [27]. In most healthcare settings, workers are highly dependent on each other when caring for and treating patients [34]. When jobs are highly interdependent, healthcare workers need to mutually adjust and coordinate their efforts to realize high quality care. Especially when these mutual adjustments require face-to-face interactions, there will be ample opportunities to develop relationships with others, and the extent to which these relationships are positive or negative will affect the fulfilment of the need for relatedness [27, 35].
The introduction of an EHR, however, implies that these mutual adjustments are much more controlled by the digital system; this will be accompanied by the standardization of operating procedures so that work practices of different health care workers become tightly coupled and more interdependent [7, 15, 19, 36]. For example, in the hospital setting, the EHR might require the surgeon to place an order in the system for patient transfer from the operating room to the intensive care unit (ICU). Before EHR implementation, ICU workers could immediately start providing care, whereas after EHR implementation, they have to await the surgeon’s order before being able to access the patient record and start providing care. As illustrated by this example, interdependence may lead to production blocking and process losses because employees have to wait for the input of others [37]. In such cases, interdependence may even lead to conflicts [38] that further impair positive interactions [39]. Furthermore, due to EHRs, the need for face-to-face interactions will be lessened [1, 19, 40, 41]. As such, an EHR may decrease the opportunities for employees to develop positive social relationships [27, 42], while high-quality interpersonal relationships are especially important in highly interdependent work settings [43]. Less positive relationships lower the level of satisfaction of the need for relatedness. According to the SDT, this will have a negative influence on autonomous work motivation [8, 9, 26].
Following the arguments above, we hypothesize that the introduction of an EHR will be associated with an increase in healthcare workers’ perceptions of interdependence (Hypothesis 2a), and that perceptions of interdependence will be negatively related to autonomous motivation (Hypothesis 2b). Taken together, we anticipate that EHR implementation is negatively related to healthcare workers’ autonomous motivation through (i.e., mediated by) perceived interdependence (Hypothesis 2c).
Professional differences
The healthcare workforce in hospitals is diverse, being constituted by workers from various occupational backgrounds, including nurses, physicians, physician assistants, social workers, dieticians, and administrative workers. Physicians, nurses and allied healthcare professionals (HCPs) are highly trained and socialized within their profession [5, 44, 45] and complex (in)formal hierarchies exist amongst these different professions, in which roles and responsibilities depend on one’s position in the hierarchy [15, 46]. This diversity might be reflected in people’s responses to the implementation of an EHR [5, 14, 46]. The distinct roles and methods of socialization amongst healthcare workers are likely to cause them to value and experience their work context and the EHR differently. For example, physicians traditionally hold a highly autonomous, self-regulating role [33]. It is possible that due to their traditionally high levels of autonomy, they value autonomy more than the other professions, and changes in autonomy may therefore be more salient to them [5, 7].
There is little existing knowledge about professional differences in the consequences of technology implementation to build upon, and roles and hierarchies within healthcare may be affected by digitalization [5, 15, 47]. Therefore, rather than formulating directional hypotheses, this study explores the moderating role of profession on the relationship between EHR implementation and work characteristics. In other words, we will explore whether any differences exist between four professional groups of healthcare workers (nurses, physicians, allied HCPs, and administrative workers) regarding the changes in their levels of autonomy and interdependence after EHR implementation.