Accountability focus and nurses' performance: A moderated-mediation model by using experiment design simulations

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Aim: The aim of this study was to test a moderated-mediation model, explaining how and under which circumstances a process- or an outcome-accountability focus affects performance. Design: Randomized controlled design, using screen-based simulations. Methods: Data were collected during 2021. Two screen-based simulations of medication administration (for low- and high-complexity tasks) were used. Each participant was randomly assigned to one of the six experimental conditions. Nurses completed validated questionnaires on strain levels and their perceptions of the simulated task complexity and accountability focus. Performance was assessed via validated checklists assessing nurses' performance of the simulation. Results: Task complexity significantly moderated the relationship between accountability-focus conditions and strain. For the process-accountability-focus condition, strain levels were lower during high-complexity tasks compared with low-complexity tasks, while for the outcome-accountability-focus condition, strain levels were lower during low-complexity tasks compared with high-complexity tasks. The highest strain levels were observed under the no accountability-focus condition. Additionally, this interaction had an impact on performance, with nurses' strain playing a mediating role. Conclusions: Any accountability focus reduces strain levels and enhances performance compared with having no accountability focus. The choice of accountability focus should be based on task-complexity considerations. Implications for the Profession and Patient Care: Managers can effectively reduce nurses' strain and improve performance by prioritizing outcome accountability focus for simpler tasks and process accountability focus for complex tasks. Impact: The study addressed previous ambiguous findings regarding the type of accountability focus that better motivates nurses' performance. By considering accountability focus, nurse managers can balance nurses' strain levels with improved performance. Reporting Method: We have adhered to the relevant EQUATOR guidelines: CONSORT. Patient or Public Contribution: There is no patient or public contribution, as the study only concerns the providers of the service, that is the nurses themselves.

Original languageEnglish
Pages (from-to)1144-1153
Number of pages10
JournalJournal of Advanced Nursing
Issue number3
StatePublished - Mar 2024

Bibliographical note

Publisher Copyright:
© 2023 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.


  • accountability focus
  • medication administration, moderated-mediation model
  • performance
  • strain
  • task complexity

ASJC Scopus subject areas

  • General Nursing


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