Fading Focus: Addressing the Association Between Challenge Stressors,Role Blurring,Insomnia,Fatigue,and Workplace Cognitive Failure

Abstract

The primary goal of the present study is to inspect the plausible job-related (i.e., challenge stressors and role blurring) and individual factors (i.e., fatigue and insomnia) that potentially lead to work-related cognitive failures among healthcare staff. Through the judgmental sampling technique, data was collected from healthcare personnel in Iran. The results revealed that challenge stressors in the form of time pressure, job responsibility, and work overload are significantly related to role blurring. Moreover, role blurring increases fatigue and insomnia among medical staff, and both insomnia and fatigue cause workplace cognitive failure. The results also confirm the mediation effect of role blurring in the association between challenge stressors, insomnia, and fatigue. According to the results, insomnia and fatigue similarly mediate the role blurring on workplace cognitive failure association. Theoretical implications, useful suggestions for practitioners, and prospective research avenues are debated in the study.

Keywords

challenge stressors role blurring insomnia fatigue workplace cognitive failure healthcare staff

Introduction

Healthcare staff play a key role in keeping patients safe and achieving optimal health outcomes (Arnetz et al., 2021). Given their duty to complete many and frequently cognitively demanding job tasks with little to no opportunity for error, possible distractions must be minimized or removed entirely (Cambier et al., 2020). A common work-related error is known as cognitive failure, which is described as mistakes or failures in completing a job that a person is typically capable of performing, and they encompass all sorts of execution and storage failures, with the exception of failures of ability or knowledge (Martin, 1983; Wallace et al., 2003). Due to lengthy working hours and exhaustion, medical personnel are prone to making errors during task performance. These mistakes and workplace cognitive failures are likely to result from workflow interruptions caused by coworkers, patients, and organizational stress (Abbasi et al., 2017). With this in mind, it seems indispensable to reveal probable job-related and individual factors and causes that could potentially lead to work-related cognitive failures among this occupational group.

Broadly speaking, task-related stressors in the healthcare context put high demands on cognitive control and, therefore, may increase the risk of cognitive failures among healthcare staff (Elfering et al., 2011). Stressors that are associated with medical personnel include work overload, time pressure, distractions, role conflict, and job responsibility (Deng et al., 2019; Elfering et al., 2011; Yildirim & Aycan, 2008), which are related to the umbrella concept of job-related stressors (Cavanaugh et al., 2000). Cavanaugh et al. (2000) classified stressors into two distinct categories known as hindrance and challenge stressors. Hindrance stressors (e.g., role ambiguity, role conflict) have been found to be negatively related to motivation and work effectiveness (Crawford et al., 2010), whereas challenge stressors (e.g., work overload, time pressure) have been presented to prompt employees’ inspiration and work outcomes (LePine et al., 2005). A preponderance of the evidence has similarly revealed the positive and favorable outcomes emerging from challenge stressors (Crane & Searle, 2016; Deng et al., 2019; Karatepe et al., 2014); yet some have questioned this conventional conception and debated the opposite scenario by contesting the negative effects of challenge stressors (Olugbade & Karatepe, 2019; Rosen et al., 2020). As confirmed by Schieman and Young (2013), individuals who are under a lot of work pressure are more likely to feel overwhelmed by the amount of work that needs to be done. Eventually, perceived work pressure may lead to employees devoting additional non-work time to meet job demands and stay connected with work-related activities (and thoughts) outside of the traditional workplace parameters. Challenge stressors in the form of work overload, job responsibility, and time pressure would similarly cause employees to experience a high level of integration between professional and family roles. This is acknowledged as role blurring in the organizational context. As defined by Desrochers et al. (2005), role blurring is “the perception of uncertainty or difficulty in distinguishing one’s work role from one’s family roles (e.g., as parent or spouse) that occurs when these roles are seen as highly integrated” (p. 443). Debated by Schieman and Glavin (2016), role blurring comprises a set of interconnected activities that include behavioral indicators (e.g., multitasking on work and family matters and being called for business-related matters while at home) and psychological indicators (e.g., having job-related thoughts while at home) (Voydanoff, 2007).

All role blurring activities are positively associated with construction professionals’ experience of work-to-family conflict, which subsequently leads to sleep problems (Zhang & Bowen, 2021) and workplace fatigue (Brown et al., 2017). When facing role blurring, individuals are subjected to extra commitments of time and energy, which similarly weaken optimal functioning in nonwork roles (Schieman & Badawy, 2020a; Sonnentag, 2001). Given this fact, it is presumed that other probable unfavorable individual outcomes of role blurring could be manifested in the form of fatigue and insomnia. Several factors have been identified as contributing to fatigue, including shift work (Dawson et al., 2014), sleep disturbance, and high job demands (International Civil Aviation Organization, 2016). Furthermore, insomnia, defined as the occurrence of inadequate and insufficient sleep despite having ample time in bed, has been linked to decreased productivity and work-related accidents (Drake et al., 2003).

Significance and Contributions of the Study

According to the following discussion, the primary goal of the present study is to inspect the plausible job-related (i.e., challenge stressors and role blurring) and individual factors (i.e., fatigue and insomnia) and sources that potentially lead to work-related cognitive failures among healthcare staff. In doing so, the study proposes a new linear conceptual model that empirically tests the following relationships: a) the positive relation between challenge stressors and role blurring, b) the positive relation between role blurring, fatigue, and insomnia, c) the positive impact of fatigue and insomnia on work-related cognitive failures. The model also examines the mediation of role blurring in the association between challenge stressors, fatigue, and insomnia, and the mediation of fatigue and insomnia in the association between role blurring and work-related cognitive failures. To justify the relationships between the aforementioned relations, the study will apply the transactional theory of stress (Lazarus & Folkman, 1984), the role strain theory (Goode, 1960), and the Cognitive Activation Theory of Stress (CATS) (Ursin & Eriksen, 2004). The contribution of the current study could be presented from three notable perspectives.

To begin with, errors in the provision of health services are perilous behavior and in some circumstances irrevocable (Kakemam et al., 2019). Medical errors and workplace cognitive failures among healthcare staff are among the main causes of death in many countries. For instance, in the USA, about 44,000 to 98,000 patients lose their lives each year as a result of medical errors, which are the eighth leading cause of death (Abbasi et al., 2017). According to a 2017 regular review study, the prevalence of medication errors by healthcare personnel in Iranian hospitals was 53%, ranging from 17% to 88%; though, the frequency of medical errors is much higher than stated in the official report (Ranaei et al., 2020). In light of this, it is crucial to look into the variables that could lead to cognitive failures among healthcare staff. This study responds to repeated requests for additional research (Kakemam et al., 2019; Mehri et al., 2022) that emphasizes the need to identify and address the factors that contribute to cognitive failures among the aforementioned occupational group. A deeper understanding of the factors that potentially impact cognitive function is crucial for promoting a healthy and safe work environment for healthcare professionals.

Besides, though the majority of prior studies have verified the implication of challenge-hindrance stressors in organizations, which reflect opportunities or obstacles to task accomplishment and growth (Cavanaugh et al., 2000), some have questioned this classic distinction (Rosen et al., 2020). As evidenced by the former findings, it may not always be simple to classify job demands as stressors or challenges (Bakker & Sanz-Vergel, 2013). Challenge stressors can be considered hindrance stressors in one occupational setting (Olugbade & Karatepe, 2019). However, to the best of the authors’ knowledge, there is a paucity of research examining the negative implications of challenge stressors in the form of work overload, job responsibility, and time pressure, with a focal focus on the healthcare setting. The current study differs significantly from previous research, as we focus on the negative impacts of challenge stressors on job-related and individual factors that ultimately lead to workplace cognitive failures among healthcare personnel.

Last, but not least, conferring the target group and sample selection, according to the latest claim in late December 2022 by the deputy of Nursing, Ministry of Health and Medical Education, Iran is currently facing a serious shortage of workforce, and the Ministry of Health itself is looking to attract new personnel in any way (https://www.behdasht.gov.ir/). It is explicitly stated that the country requires 100,000 healthcare staff as of December 2022. Despite this fact, Iran has also been reported as the 10th top country in terms of the value of medical tourism, and it has been popular for doing treatment during travel (Moghimehfar & Nasr-Esfahani, 2011), especially family travel from Gulf countries to Shiraz and Mashhad, two cities in Iran (Rokni et al., 2013). Several competitive advantages have been listed for Iran’s medical tourism, ranging from “the valuable medical resources, infrastructure, and medical skills” to “cultural and social similarities with the border countries,” besides “religion-based factors,” and also a considerable number of Iranians living in foreign countries, who prefer to travel back to their country of origin for treatments (Tourani et al., 2010). This contributes to an additional US dollar of income for the country and creates direct and indirect job opportunities. However, the workforce shortage imposes lots of additional pressure on the current staff in healthcare centers in Iran. The results to be derived from this inquiry are expected to add value to the knowledge and literature by inspecting the factors that potentially lead to workplace cognitive failures among this occupational group.

Hypotheses Development

Challenge Stressors and Role Blurring

While most research has focused on discussing the favorable outcomes of challenging stressors within organizations, a handful of studies have deliberated on the negative effects caused by challenge stressors (e.g., Li et al., 2023; Rukundo et al., 2020). As stated by Rodell and Judge (2009), challenge stressors can lead to negative behaviors, such as counterproductive behaviors, through anxiety. More specifically, high job responsibility and work overload can make it challenging for individuals to separate their professional and personal lives, leading to the spillover of stress from work into personal life and vice versa (Bell et al., 2012). The evidence also proves that perceived time pressure was associated with poorer work-life balance and increased conflict between work and personal lives (Kusena, 2023).

Schedule-controlling individuals similarly may find it difficult to balance the demands of their work and nonwork tasks, which can result in a blurring of the lines between work and family (Badawy & Schieman, 2020a). This role blurring, associated with higher levels of work-to-family conflict, is contingent on workers’ access to and exposure to certain job resources and demands (Glavin & Schieman, 2011). Moreover, time pressure, as another job demand, would be acknowledged as a major cause contributing to role blurring. When high role expectations are not met promptly and are not supported by the skills and talents necessary to handle them, role blurring happens (Schieman & Badawy, 2020b). This implies that a lack of time might cause people to become ineffective at managing several responsibilities, which can lead to role blurring.

The relationship between challenge stressors and role blurring can be understood through the lens of the transactional theory of stress (Lazarus & Folkman, 1984). As per this theory, stress is a byproduct of interactions between people and their surroundings. It entails both primary assessment (assessing the circumstances) and secondary assessment (assessing one’s ability to cope). High challenge stressor levels might cause people to devote more time and energy to their jobs, which can exacerbate the blurring of the lines between personal and professional lives. While facing challenge stressors, medical personnel invest more time in professional activities which contributes to role blurring. To sum up:

H1: Challenge stressors in the forms of work overload, job responsibility, and time pressure are positively related to role blurring.

Role Blurring, Insomnia, and Fatigue

Role blurring refers to the interference of symptoms from one role with another role, such as work-related fatigue interfering with personal life (Minihan et al., 2022). This concept is particularly relevant in understanding the impact of occupational stress on insomnia, as seen in individuals experiencing strain-based conflict, where symptoms of fatigue from their professional role intrude and interfere with their personal lives, potentially contributing to insomnia (Minihan et al., 2022). Understanding the relationships between role blurring, insomnia, and fatigue is crucial for developing interventions to address insomnia and fatigue, especially in vulnerable populations such as healthcare workers (Brown et al., 2017).

Role blurring has been related to fatigue in numerous contexts. For example, role blurring has been observed to raise job tiredness in the context of work-life balance, (Göktaş, 2023; Minihan et al., 2022; Palumbo, 2020). This relationship is particularly significant in performance-oriented work environments with blurred working time boundaries, where it can lead to mental fatigue among employees (Fan & Smith, 2018).

Additionally, the relationship between role blurring and insomnia has been a subject of interest in various contexts. Role blurring has been linked to sleep disturbances, including insomnia, among individuals working from home (Molino, 2023). This relationship is further supported by the finding that supervisor support is positively related to mastery, which in turn is negatively associated with insomnia (Molino, 2023).

The relationship between role blurring, insomnia, and fatigue can be understood through the lens of role strain theory (Goode, 1960). As per this theory, individuals experience strain when they struggle to meet the demands and expectations associated with their roles. Role blurring can occur when there is an overlap or conflict between different roles, such as work and personal life (Gajendran & Harrison, 2007). The tension that results can cause psychological anguish, which makes it harder for people to wind down and relax. This, in turn, can exacerbate tiredness and lack of sleep. Thus:

H2: Role blurring is positively and significantly related to insomnia.

H3: Role blurring is positively and significantly related to fatigue.

Insomnia, Fatigue, and Workplace Cognitive Failure

The relationship between insomnia and workplace cognitive failure in healthcare staff is a critical area of concern, particularly given the potential impact on patient care and staff well-being. Research has shown that the severity of insomnia is positively related to cognitive failures, even after controlling for confounds such as depression, stress, and anxiety (Carrigan & Barkus, 2016). Another recent study found that workplace productivity was affected by insomnia severity (Chalet et al., 2023). Insomnia has also been found to predict workplace cognitive failures and safety behaviors, suggesting a link between sleep and work behaviors (Brossoit et al., 2019). Moreover, a field study on the cognitive performance of staff provided evidence for the relationship between work-related fatigue and performance impairment, highlighting the impact of fatigue on cognitive function in the workplace (Fan & Smith, 2020). Another study on job characteristics in nursing also found associations between job demands, fatigue, and cognitive failure at work, highlighting the relevance of occupational factors in understanding workplace cognitive failure (Elfering et al., 2011).

CATS (Ursin & Eriksen, 2004) provides a comprehensive framework for understanding the relationship between fatigue, insomnia, and cognitive failure. The theory provides a framework for understanding the impact of arousal levels on cognitive performance in stressful situations (Ursin & Eriksen, 2004). Insomnia is often associated with disrupted sleep patterns and inadequate rest. According to CATS, individuals experiencing insomnia may have elevated arousal levels, as the lack of quality sleep leads to a chronic state of physiological and psychological activation (Thiart et al., 2013). Increased arousal, in the context of insomnia, can result in persistent cognitive activation even during non-stressful tasks, making it difficult for individuals to effectively regulate their attention and energy. CATS also suggests that fatigue can lead to cognitive failure by disrupting the optimal level of cognitive activation. As fatigue increases, it can push individuals into a state of low cognitive activation, negatively impacting attention, memory, and executive functions, ultimately resulting in workplace cognitive failures. Thus:

H4: Insomnia increases the level of workplace cognitive failure.

H5: Fatigue increases the level of workplace cognitive failure.

The Mediation Effect of Role Blurring

The relationships that have been shown thus far imply the mediation of role blurring in the association between challenge stressors, insomnia, and fatigue. Job demands are likely to lead to resource drain and work-family conflict (Michel et al., 2010). Specifically, job pressure is associated with emotional exhaustion among healthcare workers, indicating its potential impact on role blurring (Dodanwala et al., 2022). Evidence indicates that challenge stressors are associated with psychological strains, such as emotional exhaustion and tension, which are indicative of fatigue (El-Dokani et al., 2018). Likewise, Glavin and Schieman (2016) highlighted that role blurring is associated with higher levels of work-to-family conflict, which can contribute to fatigue. As confirmed by Crane and Searle (2016), resilience mediated the relationship between stressors and strain, suggesting that individuals’ ability to cope with stressors may impact their experience of fatigue. Another empirical study also emphasized the relationship between role blurring and its consequences, such as distraction and interruption, which can contribute to mental fatigue (Schieman & Glavin, 2016). Additionally, Kalmbach et al. (2018) highlighted the influence of environmental stress on the sleep system, indicating that stress can impact sleep reactivity and contribute to insomnia vulnerability. Furthermore, Zou et al. (2021) demonstrated that occupational stressors were associated with anxiety, depression, and insomnia symptoms, suggesting a potential link between stress and insomnia.

The relationship between challenge stressors, role blurring, fatigue, and insomnia is influenced by various factors such as individual appraisal, coping mechanisms, and work-family dynamics. Therefore, this study would suggest that role blurring serves as a mediator in this relationship by intensifying the impact of challenge stressors on insomnia and fatigue. When faced with high levels of time pressure, job responsibility, and work overload, healthcare staff will face role blurring in various ways, such as being available after work hours or on weekends in case a problem at work comes up. The continuous engagement with work-related concerns due to role blurring may create a persistent state of arousal, contributing to insomnia, and the resulting fatigue may be more pronounced due to the extended cognitive activation. Therefore, the following hypothesis is proposed:

H6: Role blurring mediates the relationship between challenge stressors and insomnia.

H7: Role blurring mediates the relationship between challenge stressors and fatigue.

The Mediation Effect of Insomnia and Fatigue

Role blurring in the workplace occurs when individuals experience challenges in maintaining clear boundaries between their professional roles and personal lives (Schieman & Glavin, 2016). This blurring can result in various negative outcomes, including an impact on cognitive performance and an increase in workplace cognitive failure (Elfering et al., 2011).

Richter et al. (2016) also highlighted the negative effects of excessive fatigue and insomnia on work performance, processing errors, and accidents, indicating the potential impact of these factors on workplace cognitive failure. The evidence also reveals that poor sleep quality and fatigue are correlated with being more distracted at work and having lower work situation awareness (Brossoit et al., 2019).

Given the information presented so far, this study suggests that insomnia and fatigue may act as mediators in the connection between role blurring and workplace cognitive failure.

Healthcare professionals facing role blurring struggle to detach from work-related thoughts and responsibilities outside of their working hours. This may contribute to a chronic state of mental activation and result in insomnia (Chalet et al., 2023). Role blurring can also contribute to fatigue, both physical and mental, due to the extended engagement with work-related tasks (Tang & Huang, 2016). This situation eventually leads to difficulties in modulating attention and cognitive resources, increasing the likelihood of cognitive failures in the workplace. Therefore,

H8: Insomnia mediates the relationship between role blurring and workplace cognitive behavior.

H9: Fatigue mediates the relationship between role blurring and workplace cognitive behavior.

Methodology

This examination demonstrates that while healthcare staff are under high pressure (challenge stressors), they must devote time to carry out their responsibilities outside their working hours (role blurring). As a result, they will become more tired (fatigue) and suffer from sleep disorders (insomnia), which consequently create cognitively-based human errors that occur at work (workplace cognitive failure). Figure 1 depicts the conceptual model and hypotheses. Accordingly, role blurring mediates the relationship between challenge stressors, fatigue, and insomnia. Additionally, insomnia and fatigue mediate the relationship between role blurring and workplace cognitive failure.

Figure 1.

Conceptual Model and Hypotheses

The data for this study were obtained via a judgmental sample of full-time doctors and nurses working in private and public hospitals in Tehran, Iran. Judgmental sampling, a non-probability sampling method, relies on the researcher’s expertise and judgment to select specific cases or individuals for a study (Van De Ven & Johnson, 2006). To accomplish this, the research team directly informs supervisors about the study’s primary objective and obtains permission.

Our study controlled for common method variance through the time-lagged data to reduce common rater effects and illusory correlations (Podsakoff et al., 2003) and created a temporal separation by introducing a 2-week time lag between the measurement of the predictor and criterion variables. This technique is in line with previous studies (e.g.: Bouzari & Karatepe, 2017). This research applied the back-translation technique proposed by McGorry (2000). The pilot study included twenty healthcare staff to ensure that the translated items were understandable. No changes were necessary based on the results of the pilot study.

Based on the information gained by the research team, there are around fifteen thousand full-time doctors and nurses employed in Tehran. Consequently, the research team requires an approximate sample size of 385 nurses to gauge the population proportion with a 5% margin of error and a 95% confidence level.

The researchers distributed 370 questionnaires and received 316 questionnaires (response rate: 85.40 %). The majority of participants were between the ages of 38 and 47 (37.97 %), male (64.56 percent), married (69.30 %), and had a tenure of 6–10 years (34.49 %). Table 1 details the demographics of the respondents.

Table 1.

Respondents’ Profile (n = 316)

Demographic variables	Frequency	(%)
Age
18–27	36	11.39
28–37	98	31.01
38–47	120	37.97
48 or above	65	19.63
Gender
female	112	35.44
Male	204	64.56
Marital status
Married	219	69.30
Single or divorce	97	30.70
Tenure
Less than 1 year	42	13.29
1–5 years	98	31.01
6–10 years	109	34.49
More than 11 years	67	21.21

Measurements

Work overload items have been adopted from Price (2001). Job responsibility items have been taken from Hackman and Oldham (1975). Time pressure items have been used in the Putrevu and Ratchford (1997) study. Role blurring items were taken from Schieman and Badawy (2020a). For insomnia, items were taken from the study of Pallesen et al. (2008), and fatigue items were adopted from Flachenecker et al. (2002). Information about the Likert scale has been presented in Table 2.

Table 2.

Confirmatory Factor Analysis

Items	Standardized loadings	t-value
Work overload – Price, 2001 - five-point scales	0.71	14.01
1. I Do not have enough time to get everything done in my job	0.73	14.40
2. My workload is heavy on my job	0.69	13.79
3. I Have to work very hard in my job	0.72	14.17
4. I Have to work very fast in my job
Job responsibility – Hackman & Oldham, 1975 - five-point scales
1. I Feel a very high degree of personal responsibility for the work I do on this job	0.82	16.43
2. I Feel I should personally take the credit or blame for the results of my work on this job	0.75	15.01
3. Whether or not this job gets done right is clearly my responsibility	0.80	16.21
4. It is hard, on this job, for me to care very much about whether or not the work gets done right	0.89	17.57
Time pressure – Putrevu & Ratchford, 1997 - seven-point scales
1. I Find myself pressed for time when I go to work	0.83	16.71
2. I Am in a hurry when I do my work	0.83	16.69
3. I Have only a limited amount of time in which to finish my work	0.89	17.81
4. I Finish my work fast because I have other things to do	0.87	17.48
5. I Have more than enough time to complete my weekly work (reverse coded)	-	-
Role blurring – Schieman & Badawy (2020b) - - five-point scales
1. How often do you do any paid or unpaid work at home that is part of your job?	0.94	19.60
2. How often do coworkers, supervisors, managers, customers, or clients contact you about work-related matters outside of your normal work hours?	0.96	20.01
3. How often do you try to ‘multitask’—that is, work on job tasks and home tasks at the same time while you are at home?	0.94	19.69
4. Employees where I work are often expected to take work home during nonwork hours and/or nonwork days	0.89	17.61
5. I Need to be available after work hours or on weekends in case a problem at work comes up	0.86	17.37
Insomnia – Pallesen et al., 2008 - seven-point scales
1. During the past month, how many days a week has it taken you more than 30 minutes to fall asleep after the light was switched off?	0.82	16.50
2. During the past month, how many days a week have you been awake for more than 30 minutes between periods of sleep?	0.89	17.79
3. During the past month, how many days a week have you awakened more than 30 minutes earlier than you wished without managing to fall asleep again?	0.79	15.46
4. During the past month, how many days a week have you felt that you have not had enough rest after waking up?	0.81	16.72
5. During the past month, how many days a week have you been so sleepy/tired that it has affected you at school/work or in your private life?	0.80	16.19
6. During the past month, how many days a week have you been dissatisfied with your sleep?	0.74	14.82
Fatigue – Flachenecker et al., 2002 - five-point scales
1. I Feel less alert	0.88	17.50
2. I Have difficulty paying attention for a long period of time	0.81	16.69
3. I Feel like I cannot think clearly	0.79	15.55
4. I Am more clumsy and uncoordinated	0.81	16.61
5. I Find that I am more forgetful	0.80	16.49
6. I Have to limit my physical activities	0.78	15.06
7. I Am less motivated to do anything that requires physical effort	0.79	15.82
8. I Am less motivated to engage in social activities	0.76	15.48
9. I Am limited to do anything outside my home	0.86	17.42
10. I Have trouble maintaining physical effort for long periods	0.84	16.81
11. I Find it difficult to make decisions	0.92	18.91
12. I Am less motivated to do anything that requires thinking	-	-
13. I Feel weak	-	-
14. My physical discomfort is increased	0.91	18.85
15. I Am less able to finish tasks that require thinking	0.86	17.39
16. I Find it difficult to organize my thoughts when I am doing things at home or at work	-	-
17. I Am less able to complete tasks that require physical effort	0.79	15.77
18. I Feel slowed down in my thinking	0.72	14.68
19. I Find it hard to concentrate	0.80	16.85
20. I Have to limit my physical activities	0.68	14.67
21. I Require more frequent or longer periods of rest	0.84	16.79
Workplace cognitive failure - Wallace & Chen (2003) - five-point scales
1. Cannot remember whether you have or have not turned off work equipment	0.76	15.43
2. Fail to recall work procedures	0.77	15.53
3. Cannot remember work-related phone numbers	0.76	15.40
4. Cannot remember what materials are required to complete a particular task	0.74	15.21
5. Forget where you have put something you use in your job (e.g. tools)	0.90	18.66
6. Fail to notice postings or notices on the facilities bulletin board(s) or email system	0.77	15.60
7. Do not fully listen to instruction	0.86	17.22
8. Day-dream when you ought to be listening to somebody	0.78	15.71
9. Do not focus your full attention on work activities	0.81	16.58
10. Are easily distracted by co-workers	0.76	15.59
11. Accidentally drop objects or things	0.73	15.02
12. Throw a way something you meant to keep (e.g. memos, tools)	0.72	14.91
13. Say things to others that you did not mean to say	0.77	15.62
14. Unintentionally press control switches on machines	-	-
15. Accidentally started or stopped the wrong machine	-	-

Note. Model fit statistics χ² = 353.52; df = 179; χ²/df = 1.98; CFI = 0.95; PNFI = 0.88; RMSEA = 0.063; SRMR = 0.005.

Data Analysis

This investigation employed structural equation modeling with Lisrel 8.30 (Joreskog & Sorbom, 1996). The study utilized a two-step method following Anderson and Gerbing’s approach (1988). Confirmatory factor analysis and the assessment of composite reliability (Anderson & Gerbing, 1988; Fornell & Larcker, 1981) were the initial techniques applied.

The results of the confirmatory factor analysis suggested the deletion of several items due to low standardized loading (˂ 0.50), as shown in Table 2. Upon removing these items, the outcomes indicated that the remaining observable indicators exhibited significant loadings on their corresponding constructs. By excluding the low-loading items, the findings demonstrated a good fit to the data: χ² = 353.52; df = 179; χ²/df = 1.98; CFI = 0.95; PNFI = 0.88; RMSEA = 0.063; SRMR = 0.005.

The standardized loadings, which varied from 0.68 to 0.96, demonstrated statistical significance. Each latent variable recovered an average variance of more than 0.50, indicating convergent validity. Additionally, shared variances (Φ2) between construct pairs were lower than the Average Variance Extracted (AVE) of each construct, indicating discriminant validity (Fornell & Larcker, 1981).

To examine the likelihood of common method bias, we utilized Harman’s single-factor test and conducted confirmatory factor analysis. The single-factor model explained merely 21% of the total variation, which is less than half (McFarlin & Sweeney, 1992). Therefore, the findings indicate that common method bias is not a notable concern in this study. Furthermore, the composite reliability for each construct exceeded the predefined threshold, and the coefficient alphas were above 0.70, affirming the reliability of all measurements (Bagozzi & Yi, 1988). Table 3 presents the AVE, composite reliability, Cronbach’s α means, standard deviations, and correlations of observed variables.

Table 3.

Summary Statistics and Correlations

Variables	1	2	3	4	5	6	7	8	9	10	11
1. Age	-
2. Gender	0.016	-
3. Marital status	0.002	0.002	-
4. Tenure	0.095	0.095	0.095	-
5. Work overload	0.090	0.094	0.011	0.202**	-
6. Job responsibility	0.053	0.014	0.042	0.218**	0.119*	-
7. Time pressure	0.046	0.027	0.089	0.203**	0.240**	0.210**	-
8. Role blurring	0.004	0.017	0.092	0.197*	0.007	0.245**	0.226**	-
9. Insomnia	0.087	0.095	0.041	0.248**	0.207**	0.197*	0.155*	0.253**	-
10. Fatigue	0.012	0.097	0.029	0.208**	0.246**	0.221**	0.239**	0.176*	0.245**	-
11. Workplace cognitive failure	0.039	0.044	0.100	−0.213**	0.191*	0.222**	0.120*	0.213**	0.241**	0.207**	-
AVE	-	-	-	-	0.51	0.67	0.73	0.87	0.68	0.67	0.57
CR	-	-	-	-	0.80	0.89	0.91	0.97	0.94	0.99	0.98
Cronbach’s α	-	-	-	-	0.81	0.89	0.90	0.96	0.94	0.98	0.98
Mean	2.24	0.59	1.63	2.48	3.29	3.63	5.24	3.69	6.11	4.09	3.11
Standard deviation	1.03	0.49	0.73	1.19	0.67	0.42	0.71	0.88	0.46	0.32	0.77

Note. ^*p < .05(one-tailed test);^**p < .01(two-tailed test).

Hypotheses Testing

Skewness was employed as an assessment of data normality, and the values, all below 3.00 (Kline, 2011), indicated no presence of non-normality.

In the second phase, the study hypotheses were tested through structural equation modeling, as outlined by Joreskog and Sorbom (1996). Table 4 displays the fit indices for the mediation mode (χ² = 269.52; df = 159; CFI = 0.96; PNFI = 0.91; RMSEA = 0.053; SRMR = 0.003). As manifested by work overload, job responsibility, and time pressure, challenge stressors are significantly and positively related to role blurring (γ₂₁ = 0.18, t = 2.78). Hence, hypothesis 1 is supported. Moreover, the results showed that role blurring exerts significant positive effects on insomnia (β₃₂ = 0.22, t = 3.51) and fatigue (β₄₂ = 0.17, t = 3.63). Consequently, hypotheses 2 and 3 are supported. Furthermore, the results showed that insomnia and fatigue are significantly related to workplace cognitive failure (β₅₃ = 0.29, t = 4.43; β₅₄ = 0.28, t = 4.57). Accordingly, hypotheses 4a and 4b are also supported.

Table 4.

Direct, Mediation and Bootstrapping

Direct Effect
			Path estimate		t-value
Hypothesis 1	Challenge stressors → role blurring		0.18		2.78^*
Hypothesis 2	Role blurring → insomnia		0.22		3.51^**
Hypothesis 3	Role blurring → fatigue		0.17		3.63^**
Hypothesis 4	Insomnia → workplace cognitive failure		0.29		4.43^**
Hypothesis 5	Fatigue → workplace cognitive failure		0.28		4.57^**
Alternative Hypotheses	Insomnia → Fatigue		0.23		4.02 ^**
Mediation effect
					z-score
Hypothesis 6	Challenge stressors → role blurring → insomnia				1.87*
Hypothesis 7	Challenge stressors → role blurring → fatigue				1.47*
Hypothesis 8	Role blurring → insomnia → workplace cognitive failure				2.51**
Hypothesis 9	Role blurring → fatigue → workplace cognitive failure				2.75**
Tenure → challenge stressors	γ = 0.17		t-value = 2.20*
Tenure → role blurring	γ = 0.19		t-value = 2.31*
Tenure → insomnia	γ = 0.21		t-value = 3.11**
Tenure → fatigue	γ = 0.23		t-value = 3.81**
Tenure → workplace cognitive failure	γ = −0.11		t-value = −2.11*
Model fit statistics: χ² = 269.52; df = 159; CFI = 0.96; PNFI = 0.91; RMSEA = 0.053; SRMR = 0.003
Alternative hypotheses
Fatigue → Insomnia → Workplace cognitive failure	Partial Mediation
Model fit statistics: χ ² = 253.22; df = 156; CFI = 0.96; PNFI = 0.93; RMSEA = 0.050
	λ	t-value			R²
Work overload	0.43	-	Challenge stressors		0.02
Job responsibility	0.31	3.08	Role blurring		0.32
Time pressure	0.28	3.16	Insomnia		0.64
			Fatigue		0.78
			Workplace cognitive failure		0.53
Bias-correlated bootstrapping
Hypothesized mediating relationship indirect	Indirect effect		LLCI	ULCI	SE
Challenge stressors → role blurring → insomnia	0.047		0.023	0.067	0.027
Challenge stressors → role blurring → insomnia	0.052		0.031	0.071	0.035
Role blurring → insomnia → workplace cognitive failure	0.049		0.029	0.059	0.036
Role blurring → fatigue → workplace cognitive failure	0.038		0.013	0.047	0.021

Note. ^*p < .05; ^**p < .01. Bias-corrected bootstrapping analysis was made using a bootstrapped 5000 sample at the 95% confidence interval. SE = Standard error; LLCI = Lower level confidence interval; ULCI = Upper level confidence interval.

The results also reveal that tenure has a significant relation with challenge stressors (γ = 0.17; t = 2.20), role blurring (γ = 0.19; t = 2.31), insomnia (γ = 0.21; t = 3.11), fatigue (γ = 0.23; t = 3.81) and workplace cognitive failure (γ = −0.11; t = −2.11).

Although it has not been hypothesized, the results reveal there is a significant relationship between fatigue and insomnia (0.28, t = 4.57). The findings are also consistent with earlier investigations. The majority of studies that explored fatigue and insomnia (Almurdi & Buragadda, 2021; Bauml et al., 2015; Gharzeddine, et al., 2020; Kalle et al., 2021; Sidani et al., 2018; Zou et al., 2021), discovered fatigue and sleeplessness are strongly related to one another.

To ensure the mediation effect, this study used two strategies. The Sobel test was first utilized in this study, which relies on the sum of independent and dependent coefficients, also known as coefficient multiplication (MacKinnon et al., 2002). The Sobel test consists of multiplying independent and dependent coefficient estimates and calculating the ratio of the resulting value to the standard error. This equation calculates the z-score for the mediating impact. This score is employed to assess if the impact of mediation is statistically significant by calculating probabilities using a standard normal distribution (Sobel, 1982). If the z-score reaches 1.96, the mediation impact is considered significant at the .05 level (MacKinnon et al., 2002; Mallinckrodt et al., 2006).

The results of the mediation hypothesis show that role blurring fully mediates the association between challenging stressors, sleeplessness (z-score = 1.87), and exhaustion (z-score = 1.47). Furthermore, the study found that insomnia fully mediates the association between challenge stressors and workplace cognitive failure (z-score = 2.51). Furthermore, the findings show that exhaustion fully mediates the association between challenge stressors and workplace cognitive failure (z-score = 2.75), as does insomnia (z-score = 2.51).

Two of the stated hypotheses’ z-scores were less than 1.96 (H6 and H7). As a result, the bootstrapping technique was applied (Hayes, 2013). Bootstrapping is a nonparametric resampling approach that, unlike existing mediation methods, evaluates mediation without relying on the sampling distribution’s normality premise. Bootstrapping is a highly computational method that involves conducting multiple resampling operations and determining the indirect effects in each resampled dataset. Repeating this process thousands of times creates a statistical method for ab sampling distribution, which is then used to establish the confidence intervals of the indirect influence (Özdil & Kutlu, 2019). Shrout and Bolger (2002) discovered that the bootstrap approach worked when the sample distribution of mediation effects was non-zero or skewed. Cheung and Lau (2008) expanded MacKinnon et al.’s (2002) simulation work, discovering that bootstrapping outperformed the Sobel test. Bootstrap confidence intervals at the 95% level did not include a zero value. Consequently, all of the mediation hypotheses have been supported (see Table 4).

Additionally, the study tried to investigate the potential mediation effect between insomnia, fatigue, and workplace cognitive failure. The results showed that fatigue partially mediates the relationship between insomnia and workplace cognitive failure (χ2 = 253.22; df = 156; CFI = 0.96; PNFI = 0.93; RMSEA = 0.050).

Discussion and Conclusion

The current study proposes a conceptual research model that empirically investigates the factors that ultimately affect workplace cognitive failure among healthcare staff. All the proposed hypotheses and the viability of the model were supported. The main findings will be outlined as follows:

To begin with, using the transactional theory of stress (Lazarus & Folkman, 1984) and the supporting evidence, the model proposed the positive relationship between challenge stressors (in the forms of job responsibility, time pressure, and work overload) and role blurring. High levels of challenging stressors could push people to dedicate more time and attention to their professions, thus blurring the distinctions between personal and professional life. When confronted with significant pressures, medical staff would devote more time to professional tasks, contributing to role blurring.

The model also proposed the positive relationship between role blurring, insomnia, and fatigue. This relation was understood through the lens of role strain theory (Goode, 1960). When there is an overlap or conflict between distinct roles, such as work and personal life, role blurring could arise (Gajendran & Harrison, 2007). Individuals get stressed when they are unable to satisfy the demands and expectations of their roles. The resulting tension can induce psychological agony, making it difficult for healthcare staff to wind down and rest, which ultimately causes fatigue. This finding is consitent with former studies (Fan & Smith, 2018; Molino, 2023).

The study also applied CATS (Ursin & Eriksen, 2004) to justify the relation between insomnia, fatigue, and workplace cognitive failure. Due to their chronic lack of good sleep, healthcare workers who suffer from insomnia frequently have elevated arousal levels, which results in ongoing physiological and psychological activity. This elevated level of arousal may cause problems with energy and attention regulation, which may activate the brain even when performing non-stressful tasks. Additionally, the theory contends that exhaustion might interfere with the ideal state of cognitive engagement, resulting in deficits in executive, memory, and attentional functions, particularly during work.

The research model also verified that role blurring mediates the relation between challenge stressors, fatigue, and insomnia. When faced with a high amount of time pressure, job responsibility, and work overload, healthcare workers may experience role blurring in a variety of ways, such as being accessible beyond work hours or on weekends in case an issue at work arises. Continuous involvement with work-related problems as a consequence of role blurring may result in a chronic state of arousal, which may contribute to insomnia, and the resultant exhaustion may be more acute as a result of the longer mental stimulation.

Additionally, as hypothesized, insomnia and fatigue both mediate the relation between role blurring and workplace cognitive failure among healthcare staff. It might be challenging for healthcare workers who encounter role blurring to put work-related ideas and obligations aside during off-peak hours. This might lead to sleeplessness and a persistent state of mental activity (Chalet et al., 2023). Due to prolonged involvement with work-related duties, role blurring can also lead to physical and mental exhaustion (Tang & Huang, 2016). This condition eventually makes it harder to control attention and cognitive resources, which raises the risk of cognitive errors at work.

Last but not least, it should be noted that, as stated previously, challenge stressors can be negatively related to favorable outcomes depending on the occupational setting (Olugbade & Karatepe, 2019). Although most of the former studies found a positive relation between challenge stressors and positive individual and organizational outcomes (Karatepe et al., 2014), in our study, challenge stressors yielded negative outcomes. Thus, it is critical to evaluate these correlations in light of their particular context, taking into account a variety of factors that may impact the observed associations.

Theoretical Implications

The results of this study provide significant novel understandings of how challenge stressors ultimately affect healthcare staff’s workplace cognitive failure and the underlying mechanisms that connect stressors to occupational cognitive error. The existing body of literature in the medical domain might benefit from the inclusion of the following theoretical perspectives.

Firstly, research on challenge stressors has mostly addressed the positive effects, except for a few studies (e.g.: Li et al., 2023; Rukundo et al., 2020). As proposed by Olugbade and Karatepe (2019), in a particular work environment, challenge stressors might be viewed as hindrance stressors. Through the lens of the transactional theory of stress, the current study endorses this claim and attests that the mentioned challenge stressors yield negative outcomes and are positively related to role blurring among medical staff.

Moreover, the study has incorporated several variables into a conceptual model and approves that role blurring has an impact on insomnia and fatigue, which ultimately affects workplace cognitive failure. These relations were supported and justified by role strain theory (Goode, 1960) and CATS (Ursin & Eriksen, 2004). This provides additional insights into the individual factors that could deteriorate cognitive function or mental processes in a work setting, having major consequences for work tasks. In a nutshell, by examining the variables that contributed to workplace cognitive failures within this occupational group, the findings of this study have enhanced our understanding and body of research.

Practical Implications

Our research has several useful ramifications for managers at healthcare centers. Reducing the blurring of roles among medical personnel is critical to upholding accountability and guaranteeing optimum patient care. As formerly stated, Iran’s healthcare centers are under a great deal of extra strain due to a lack of workers, which results in extra pressure on this occupational group. Managers should urge medical professionals to raise their concerns about any conflicts of interest or role-blurring. They should also regularly organize team-building activities to improve communication and cooperation among medical staff members. To decrease fatigue among the staff, managers, and supervisors should establish logical and consistent work schedules to ensure that there is enough time for relaxation in between shifts. When possible, they should promote regular pauses for eating, drinking, and resting to help recover. To decrease insomnia as a result of work pressure, they should also promote the use of mindfulness, relaxation methods, and counseling services. The use of technology would also be listed as a probable remedy to minimize workplace cognitive failure among healthcare staff. They should employ technological tools that can reduce the cognitive strain on healthcare personnel by automating repetitive procedures. More importantly, they should make sure that technology is easy to use and doesn’t add to mental strain.

Limitations and Avenues for Forthcoming Research

Our research bears some limitations. To begin with, as the evidence shows, employees in the healthcare sector desire noticeable leadership to handle obstacles at work like work overload and physical exhaustion (Shanafelt et al., 2020), both of which are influential factors leading to enhanced levels of workplace cognitive failure. One of the most crucial types of resources for healthcare workers has been identified as leadership support (Cho et al., 2021). Given this fact, the inclusion of positive leadership styles such as servant leadership or ethical leadership in a conceptual model would enhance our knowledge regarding the factors that impact workplace cognitive failure in the healthcare setting. Our study controlled for common method variance through the time-lagged data to reduce common rater effects and illusory correlations. Nevertheless, in future studies, using other procedural remedies, such as supervisor ratings, would be more effective.

Though the current study examined the effect of work overload, job responsibility, and time pressure as the three common forms of challenge stressors in the service sector (Karatepe et al., 2014), future studies should incorporate other sub-dimensions in the research, such as job complexity (Liu & Li, 2018), which can lead to a more comprehensive understanding of the potential impacts and effects in organizations, and the model can account for a broader variety of factors influencing the outcome of interest. Moreover, in order to have a comprehensive understanding of the effects of the variables in the current study, future research should also examine the impact of challenge stressors on insomnia and fatigue, role blurring on workplace cognitive failure, and role blurring on both insomnia and fatigue in the same context.

Moreover, the current study examined the effect of work overload, job responsibility, and time pressure as the three common forms of challenge stressors in the service sector (Karatepe et al., 2014). Future studies should incorporate other sub-dimensions in the research model, such as job complexity (Liu & Li, 2018), which can lead to a more comprehensive understanding of the potential impacts and effects in organizations and the model can account for a broader variety of factors influencing the outcome of interest.

We used cross-sectional data for this study. This practice prevents us from concluding causal factors. Future research could address the problem of causality by gathering longitudinal data. Replication studies with larger sample sizes would increase our understanding of the causes of workplace cognitive failures among healthcare personnel. Another limitation of this study is selective sampling, which may not fully represent the broader population. This could potentially bias results and limit generalizability. Future research should use more inclusive sampling methods and ensure a diverse participant pool to address this limitation. Finally, the application of cross-cultural context and analyzing the relationship in the linear conceptual model by using such data would greatly enrich the knowledge base concerning the causes of workplace cognitive failures.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Homayoun Pasha Safavi

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