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Abstract
Aims To compare burn-out in laboratory professionals (LPs) with exposure to consolidation to those without, and to investigate the role of social support as a moderator in the exposure to mergers and acquisitions (M&A).
Methods Surveys were sent to the clinical LPs, including 732 with exposure to M&A and 819 without. The dependent variable was burn-out, and the independent variable was exposure to M&A. In investigating the role of social support in exposure group, a logistic regression was used with education, time since M&A, gender, merger types, practice setting, lab hierarchy and race as covariates.
Results Exposure to M&A was associated with higher levels of burn-out (p<0.05). In logistic regression of the workforce exposed to M&A, the odds for LP developing a high level of burn-out are lowered by 7.1% for every unit of increase in social support (OR 0.93; 95% CI 0.88 to 0.98; p=0.004).
Conclusion LPs exposed to M&A are more likely to experience higher levels of burn-out but having social support can protect against burn-out, which has policy implications for leadership managing laboratories in times of M&A.
- CYTOLOGY
- MANAGEMENT
- Laboratory Personnel
Data availability statement
Data are available on reasonable request.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Mergers and acquisitions (M&As) among clinical laboratories are increasingly common. The associations of consolidations and health impacts to the laboratory workforce needs further investigation.
WHAT THIS STUDY ADDS
The study addresses the health impacts for the laboratory professionals in an era of increased consolidations in the clinical laboratory industry and how increasing meaningful collaborative social interactions can help.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
The findings suggest that hospitals and laboratories amid M&A should implement policies that promote greater collaborative social interactions within their workforce to improve wellness and reduce burn-out in laboratory professionals.
Introduction
Mergers and acquisitions (M&A) in the healthcare service sector have increased substantially in the decade since the passage of the Affordable Care Act.1 2 The trend to consolidate within the clinical laboratory sector is expected to continue because of reductions to laboratory reimbursements and the needs for laboratory capital equipment and more modern facility infrastructures.1 3–5 A synergistic M&A, characterised by merging two complementary clinical labs together, may be socially desirable since it can improve the value of the combined enterprise. The M&A, whether it be horizontal, vertical or conglomerate in nature, can enhance the overall operating and financial economies, which can ultimately benefit both the patients and insurance companies, with better, faster and lower-cost clinical test results.4 6 Despite the benefits, there is a dark side to clinical laboratory M&A. For the healthcare workforce, the stress associated with hospital and laboratory M&A may be steep, resulting in an overall reduction in quality1 7 and a higher incidence of the workforce’s morbidity and mortality.8–10
This study focused specifically on the clinical laboratory workforce, from the technicians who accessioned the requisitions and the clinical laboratorians who performed the medical testing, to the pathologists who provided the final diagnosis, since the laboratory professionals (LPs), as they are collectively known, is a group of healthcare workforce professionals that is responsible for up to 70% of all the healthcare decisions which involve some form of pathology investigation.11 12 Laboratory testing is an inherently stressful profession. According to recent workforce surveys performed, burn-out, characterised by mental exhaustion that negatively affects workplace performance, was high among pathologists and medical laboratory technologists, with a full one-third of pathologists and one-half of technologists indicating that they are currently experiencing burn-out.13–17 Therefore, it is important for hospitals and laboratory management to provide support to minimise the additional stress and negative health impacts associated with the laboratory or hospital M&A, to this already stressed workforce cohort. Our study seeks to understand the health impacts of exposures to M&A on employees’ health, in the form of burn-outs experienced, as well as applying the theory of the transactional model of stress and coping (TMSC), to assess the role of social support in M&A.
Factors associated with burn-out
Social support
According to the TMSC, when people face stressful external circumstances, social support can act as a moderator to lower the intensity of the stress the person experienced.18–20 Social support has been shown to be an effective tool for recovery in patients facing illness in hospitals. For instance, low social support has been shown to predict higher mortality in patients suffering from heart disease following a myocardial infarction or more rapid disease progression in HIV positive patients.20–22 However, there have been very few studies done on the relationships between social support in a stressful workplace environment, such as an M&A event. In theory, the LPs’ perceived level of social support will be inversely correlated with their level of burn-out, so that with more social support, the LP should experience less burn-out.
Merger and acquisitions-related predictors
The two M&A-related predictors that were selected for our model were ‘time since the exposure’ and the ‘type of M&A experienced’. Intuitively, the relationship is time-dependent in that the impact of the exposure to the stressful event, M&A, dilutes over time. Therefore, it is expected that those who experienced M&A 5 years ago will experience less burn-out than those that are currently experiencing it. The second M&A-related predictor is the nature of the merger; whether the medical LPs worked for the lab that is being targeted for acquisition (targeted) or whether they worked for one that is acquiring the other clinical facility (acquirer). According to a study that tracked 3840 unique merge activities between 2007 and 2015 in the Swedish economy, employees who worked at targeted firms are more likely to experience mental health issues and in greater severity, compared with employees from the acquiring facilities.23 Therefore, the expectation is that medical LPs that are part of the targeted labs will experience higher levels of burn-out, compared with those that are from the acquiring laboratories.
Our expectations are that the degree of the LP’s education and one’s title or role within the organisational hierarchy are both inversely correlated with the level of burn-out. LPs that have terminal degrees and are top of the laboratory hierarchy, have professional and organisational skills that are highly sought after, and in stronger demand professionally. These individuals are considered more valuable to their employers, which should translate into a higher level of job security post-M&A and garnered more respect at the workplace, compared with their blue-collar counterpart.23 24
When it comes to gender, past studies had shown that female healthcare providers, such as physicians, were 1.6 times more likely to report burn-out as compared with their male counterpart, possibly because women continued to bear a disproportionately larger share of the household responsibilities in addition to working full time and it may be more difficult to find a good work–life balance.25–27
The final two predictors that we selected for our model were race and ethnicity and workplace setting. It is expected that employees of colour or those laboratorians working in academic hospital are more likely to have a higher level of burn-out because of the implicit racism that still exist under the surface.28 29 Furthermore, there is a perception of higher workload for healthcare professionals working in hospitals, compared with reference facilities, due to the quick turnaround time expected.30 31
This M&A workforce study examined the impact of social support on LPs undergoing M&A. The goals of the study were to investigate whether the laboratory cohorts with recent exposures to laboratory M&A experienced a higher level of burn-out (a proxy for wellness) and to determine whether higher levels of social support protect the person from burn-out associated with exposures of M&A, above and beyond other commonly known M&A and demographic-related variables.
Materials and methods
A cross-sectional survey focusing on investigating burn-out and the role of social support in laboratory M&A was constructed, targeting the LP community. Research was conducted to gather information on all the M&A that have occurred in pathology and clinical laboratories in the USA in the past 5 years or between 2017 and 2022. A list of 87 reference laboratories or clinical facilities within hospitals that met the above time for exposure status were identified. An online search through social media and on pathology professional organisations’ contact databases were performed, cross-referencing the names of the M&A organisations with employees who worked in those facilities. A total of 732 laboratorians with exposure to M&A and 819 medical laboratories with unknown M&A status were targeted. Survey email invitations with consents were sent, followed by two additional reminders, between 12 December 2022 and 23 January 2023.
The cross-sectional survey instrument consisted of demographic questions followed by a section on validated psychometric instruments. The demographic questions included participants’ characteristics, such as sex, age, race/ ethnicity, education, as well as their work characteristics (work location, practice setting, departments and role within laboratory). There were also merger-related questions, such as one asking whether participants have experienced M&A in the past 5 years and whether the participant worked at the targeted or the acquiring laboratory. A final M&A question was on the amount of time passed since experiencing M&A. The psychometric instruments included the Oldenburg Burnout Inventory (OLBI) and the Social Support Provision Scale (SPS).
Measures
The outcome variable, burn-out, was measured through the OLBI consisting of 16 questions, including both positively and negatively worded questions, designed to measure employees’ burn-out through their levels of disengagement and exhaustion. It has been used in previous studies to measure burn-out for hospital and healthcare professionals.32 Each question consists of a four-point Likert scale, with a maximum total burn-out score of 64 and minimum of 16.
The SPS instrument was used to measure the level of social support experienced by the LPs. SPS is a validated assessment consisting of 24 Likert-scale questions designed to measure level of positive informal, non task-related workplace social interactions.33 34 The higher the total score on SPS represents higher positive social support experienced by the employee. Additionally, time since M&A is a measure of the number of years elapsed since a laboratorian’s exposure to M&A. Any of the participants with missing information on burn-out or not completing at least 50% of the survey questions were excluded from the study.
Statistical analysis
In descriptive analyses, a χ2 test was performed in assessing the differences in baseline demographic and work characteristics between those with exposure to M&A and those without. An independent sample t-test was then performed to determine if there is a difference in burn-out between those who experienced M&A in the past 5 years and those who did not. In exploring the second research question, whether having higher social support in time of M&A protects the laboratorian from burn-out, above and beyond all other potential covariates, a logistic regression was used in determining the role and extent social support plays for laboratory workforce during times of M&A. In the analysis, a 75th percentile was used as the cut-off for high vs low level of burn-out, after filtering out those who have no exposure to M&A, to increase specificity in regression analyses, as used in previous studies.35–39 Those with OLBI score of above the 75th percentile or 44 were assigned a score of 1; the rest (OLBI burn-out score of 44 and lower) were coded as 0. Statistical analyses were performed using the IBM SPSS Statistics for Windows, V.28.
Results
Study sample
A total of 251 survey responses were received from the 1551 targeted survey invitations sent (16.2% response rate). Out of the 251 returned surveys, 17 of them were excluded for not completing the OLBI or not completing more than 50% of the survey. Of the 234 remaining respondents in the study sample, 140 participants had experienced laboratory M&A and 94 had no exposure to M&A within the last 5 years. The baseline demographic characteristics between those who have exposure to M&A and those who do not are similar. The respondents for both groups were predominantly female (69% and 74% for M&A and no M&A, respectively), between the ages of 31 and 50 (55% and 65% for M&A and no M&A), white (59% and 53% for M&A and no M&A) and well educated, with at least a bachelor’s degree or above (94% and 97% for M&A and no M&A) (table 1).
Demographic characteristics of the participants
Similarly, there were no significant differences in the participants’ work characteristics between the ‘merger’ and the ‘no exposure to merger’ groups (table 2).
Work characteristics of the participants
The LPs who responded to the survey primarily worked in a densely populated urban area (67% and 74% for M&A and no M&A, respectively), but in a diverse practice setting, are from various departments and assumed different roles within the laboratory.
Health impacts of clinical laboratory M&As
The level of burn-out in LPs who have experienced M&A between 2017 and 2022 (n=140), were significantly higher (t=2.02, p<0.05) compared with those who have not (n=94). The clinical LPs who have not experienced M&A in the past 5 years had a mean40 burn-out score of 36.9 (6.7), with the lowest at 16 and highest at 51. By contrast, those LPs who have exposure to M&A had a mean40 burn-out of 38.8 (7.1), with the burn-out score ranging from as low as 19 to as high as 59 (figure 1).
Distribution of burn-out by frequency and merger exposure.
Within the medical laboratory group who have experienced M&A, a logistic regression model was created to investigate the role of social support in protecting against burn-out in the clinical laboratorians. Covariates (figure 2) included in the model were levels of education, time since M&A, gender, practice settings, merger status and laboratory hierarchy.
Predictors of burn-out in a laboratory mergers and acquisitions.
The results show that there is an inverse relationship between the level of social support to the intensity of burn-out. The odds for laboratorians in developing high levels of burn-out are significantly lowered by 7.1% for every incremental increase in the level of social support experienced (p=0.004), all else being equal. Surprisingly, neither merger types nor other demographic or work characteristics were significant predictors of burn-out beyond accounting for the impacts of the other variables in our model (table 3).
Logistic regression on relationships between social support and burn-out in the exposure to M&A population
Discussion
Our study addresses the critical issue of the health impacts of M&A in clinical laboratories. As expected, those who have recent exposures to M&A were associated with higher levels of burn-out, which is concerning since the M&A trend is expected to increase.41 While the distribution differences of burn-out frequency (figure 1) may seem minor between the M&A exposure and non-exposure groups, the fact that an association was found with significance means that there is enough power and its result should be perceived as meaningful by individuals and organisations.42 In other parts of the western world, researchers have observed adverse health impacts associated with M&A of the hospital employees, including a significant increase in psychotropic medication usage, particularly in M&A restructurings that involved managerial changes.43 The stress associated with organisational changes has also been linked to higher psychological disorders for the employees and the spouses.8 There is evidence that the stress and burn-out the healthcare providers experienced can also lead to a lower quality of care and services for the patients.16 44 45
Despite the association between burn-out and M&A exposure, our study result indicated that social support could protect LPs who experienced recent M&A against burn-out. This is consistent with other healthcare workforce studies, which found leadership support, as well as the quality of general workplace social interactions, to be associated with reduced burn-out in healthcare professionals.26 41 46 It is hard to accurately compare our findings to others due to a paucity of studies on this important topic. Most of the studies on M&A or wellness found in our literature review were conducted mainly in Europe, where the healthcare system is very different than in the USA.47–51 Of the few studies with a focus on the US workforce, the research target population centred primarily on nurse professionals41 or on burn-out at the workplace in general.46 Harrison and Zavotsky included nurse practitioners at a medical surgical unit, post-M&A and found that a healthy work environment is directly associated with lower turnover.41 However, the study only included 35 nurse practitioners and from a single geographical setting. In comparison, our study with 140 LPs in the USA found that social support is associated with less burn-out. In another study, Blake et al included 415 nurse practitioners but the study only assessed their work environment and the level of turnover, not specifically focusing on M&A.46 Our research is unique in that it is a study that focuses on the burn-out of the LP, and how social support level can be protective against burn-out during a time of increased healthcare consolidations.
It is surprising that there was no difference in burn-out between targeted and acquiring laboratories. One explanation is that the laboratory medical profession is unique and may be different from other industries. However, the effects of M&A are more nuanced than we anticipated and future qualitative studies that incorporate semistructured interviews of the participants may be able to provide additional insights.
Implications
Our study results have policy and public health implications. While healthcare M&A will continue, laboratory leadership can take meaningful steps to reduce the level of burn-out within its workforce during M&A through fostering improved professional social interactions and encouraging communications and support between employees and their direct supervisors. This can include scheduling regular one on one to discuss the broader work and professionally related issues as well as employees’ work ambitions and obstacles faced. A few leading institutions have also encouraged healthcare providers to meet with one another with meal reimbursement as incentives, in an effort to improve the quality of the workplace social interactions to reduce potential burn-outs.52 The laboratory that is undergoing M&A can redesign their policies to foster better professional social interactions and create a feedback mechanism for monitoring workforce wellness and burn-out levels. This can also include surveying employees’ level of burn-out and wellness regularly for trends and assessing it against its own internal wellness benchmark before and after the M&A activities. Other policy recommendations include creating an aggregate burn-out and wellness score by functional units to be part of each department’s quality metrics dashboard, to which the department managers’ performance will be based on. This will create incentives for management to be more proactive in addressing the issue.53 There is indeed a strong business case for organisations to invest in efforts to reduce LP burn-out which are often inexpensive but can make a major difference for improving pathology laboratory.54
Limitations
While the study used psychometric sound and validated instruments, it was affected by several limitations. First, the survey is longer than most, and not everyone completed the survey in its entirety, resulting in incomplete information. Second, it relied on recalling M&A activities which happened as far back as 5 years ago, which may potentially distort the results. Moreover, those who had exposure to M&A and were suffering from burn-out may be less likely to respond due to the sensitive nature of the issue and fear of repercussions from employers, but the anonymous nature and design of the survey should help assuage this fear. Furthermore, it is important to note that this study is cross-sectional in nature, which means that it can be used to find associations but not establish causation or draw causal inferences. Finally, the study’s response rate was only 16.2%. While the response rate seems low but it is still comparable to response rate of many published studies related to the LPs.55 56
Conclusion
The clinical LPs who were exposed to M&A were significantly more likely to suffer from burn-out than those who had no exposure. More importantly, the level of one’s social support can cushion one against burn-out from stressful events, such as hospital consolidations. While laboratory M&A activities will continue, improving the quality of organisational social support policies and structures will help the workforce to cope against exposure to M&A. Diagnostic laboratories amid M&A activities should redesign organisational policies to facilitate and incentivise professional social interactions to reduce workforce burn-out.
Data availability statement
Data are available on reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
The study was reviewed and approved by the university’s institutional review board (IRB No: 5220389).
Acknowledgments
The authors are grateful to Yuane Jia, PhD, Rutgers University, for her editorial assistance with the manuscript.
References
Footnotes
Handling editor Vikram Deshpande.
Twitter @chioup
Contributors PZC: conceptualisation, survey design, sample collection, data analysis, methodology, original draft writing, review and editing, RPH: conceptualisation, resources, review and editing, JO: methodology, resources, review and editing, EM: resources, review and editing. All authors have read and agreed to the published version manuscript. PZC accepted full responsibility as guarantor for the finished work and/or the conducted of the study, had access to the data and controlled the decision to publish.
Funding This study was funded by Loma Linda University, School of Public Health.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.