Nurses’ Burnout: The Influence of Leader Empowering Behaviors, Work Conditions, and Demographic Traits (2024)

Leader Empowering Behaviors

Power generally reflects the ability to control or influence others’ behaviors and attitudes.²⁶ In a work environment, power is the ability to attain, organize, and control resources, information, and support to achieve organizational goals.²⁷ The term workplace empowerment refers to employees’ ability to access the resources, information, and support needed to perform their work and to gain the opportunity to learn and develop.^27,28 Empowerment can be achieved in the work environment through LEBs.²⁹ Four categories of LEBs were developed by Conger and Kanungo in 1988, and in 1994, Hui added another category (Providing autonomy and freedom from bureaucratic restrictions) and provided a conceptual definition for each category³⁰:

• Enhancing the meaningfulness of work: leader behaviors that infuse employees’ work with purpose and give meaning to their contributions, thereby increasing employees’ sense of worth and motivating them.

• Fostering opportunity to participate in decision making: leader behaviors that allow employees to express their opinions and share in decisions related to their work.

• Expressing confidence in high performance: leader behaviors that demonstrate confidence in employees’ abilities to fulfill expectations of high performance and that recognize employees’ accomplishments.

• Facilitating the attainment of organizational goals: leader behaviors that improve employees’ skills and knowledge and provide required resources for effective performance.

• Providing autonomy and freedom from bureaucratic restrictions: leader behaviors that minimize the constrains of rules, restrictions, and commands to allow efficiency and creativity.

Hui found that LEBs have both direct and indirect influences on employees’ performance and that they significantly influence workplace empowerment. In nursing, LEBs are positively associated with nurses’ feelings of empowerment in acute care settings; in addition, both LEBs and workplace empowerment are effective in decreasing workplace tension and improving work effectiveness.³¹ Moreover, Greco et al found that LEBs have an indirect influence on emotional exhaustion via the mediation of structural empowerment and the areas of work life (workload, control, reward, community, fairness, and values).³²

Burnout

Burnout is a common psychological phenomenon among nurses. It is characterized by a decline in physical, emotional, and psychological energy resulting from work-related stress^33-35 that leads to cynicism toward clients and colleagues and feelings of low self-efficacy.³⁶ Burnout may arise because of work overload; a lack of resources, control, and justice; value conflicts; and the absence of a sense of community.³⁴ Burnout includes 3 key aspects:

• Emotional Exhaustion (EE): the state of being physically and emotionally exhausted by work stress, which is characterized by low energy, fatigue, depression, hopelessness, and helplessness.^33-35

• Depersonalization (DP): the interpersonal aspect of burnout that manifests in unfeeling, negative behaviors toward others, and detachment from caring and instructions.^33-35

• Low Personal Accomplishment (PA): the state of negatively evaluating ones’ self as being incompetent, unsuccessful, and inadequate; consequently, employees exhibit low levels of contribution to their work.^33-35

In fact, burnout is a costly problem for both organizations and employees because manifestations of burnout—including reductions in physical and psychological energy, insomnia, headache, fatigue, and depression—lead to an increase in absenteeism and turnover rates and consequently have negative effects on the quality of care.^14,34,37,38 Thus, nurse burnout has been studied widely. Abundant studies have examined the influence of different variables on burnout as part of efforts directed to reducing this phenomenon. Lower levels of burnout are associated with professional practice environment characteristics,⁶ social support,³⁹ and structural and psychological empowerment.^{9,13,14,19-22} High levels of burnout are linked to work overload,^21,39 job dissatisfaction,^6,38,39 and turnover.⁴⁰ Some demographic characteristics are associated with high levels of burnout: low education levels, night-shift work,⁴¹ and male gender with married marital status.³⁹

Design

A cross-sectional, descriptive, correlational design was used to explore the influence of head nurses’ empowering behaviors on nurse burnout.

Sample and Setting

The sample size was estimated using statistical power procedures. The researcher assumed relatively high power (0.80) to reflect higher precision, small effect size (0.03) with alpha (0.05).⁴² The estimation was based on the F test: Multiple Regression - omnibus (deviation of R² from zero), fixed model through specific software G*Power 3.1.6 for Windows. The estimated sample size was 364 participants.

The data for this study were collected from nurses employed at different teaching, private, and public—Ministry of Health (MOH)—hospitals in Jordan. The hospitals with the greatest capacity (more than 150 beds) were selected from each sector because these hospitals affect the highest number of health service providers and consumers. A convenience sample of 407 registered nurses from 11 hospitals was recruited. The inclusion criteria were as follows: registered nurses who had at least 6 months of experience in the investigated area (nurse managers not included), and who had the ability to read and understand English. English is the official language of nursing education in Jordan.

Ethical Considerations

The researchers received ethical approval to use the study instruments. Institutional review board (IRB) approval was obtained from the university (Hashemite University) and from each hospital that participated in the study. Each participant was informed of the purpose of the study, the estimated time required to complete the questionnaires, and their right to withdraw without penalty. Returning the completed questionnaires was considered to signify written agreement to participate in the study. To keep anonymity, the questionnaires did not include any information regarding the participant identity. After the nurses completed the questionnaires, the questionnaires were coded with numbers and kept in a sealed box.

Measurement

The data for this study were collected using the following tools.

Data Collection

The study data were assembled by trained research assistants, during the first 5 months of 2015. The research assistants were present in the hospital setting during the data collection process to answer any questions related to the study. Nearly 460 registered nurses were invited to participate. The response rate was approximately 88.5% (407 out of 460).

Analysis

By screening the data, few random missing data were detected and treated by imputation. Actually, no univariate or multivariate missing data were identified in this study. Descriptive and inferential statistics were employed in the analysis. Frequencies were used to describe the demographic characteristics and work conditions of the sample. Stepwise regression analysis was used to understand the influence of the head nurses’ (leaders’) empowering behaviors, work conditions, and nurses’ traits on nurses’ feelings of burnout. Before conducting the regression model, the researchers examined the data for multiple regression assumptions. To reduce potential statistical errors, the following inferential statistics were performed to determine the factors that may influence nurse burnout: (1) Pearson correlation coefficients (Pearson r) were used to assess the relationship between nurse burnout and various continuous variables, including LEBs, daily census, age, and nursing experience and (2) an 3 × 8 multivariate analyses of variance (MANOVA) was used to analyze the categorical variables for the nurses’ demographic characteristics and work conditions. Having 3 subscales of dependent variable (burnout) supports using MANOVA rather than multiple ANOVA tests to reduce the risk of type I error. To determine significant differences among groups, post hoc analysis (Tukey) was used. However, preliminary analysis did not reveal violations for the MANOVA assumptions, such as normality and linearity of the dependent variables, hom*ogeneity of variance, and independency of variables.

Demographic and Work Condition Variables

The descriptive statistics, comparisons of means, and correlations among the study variables are presented in Tables 1 and ​and2.2. A total of 407 registered nurses participated in the study. Approximately 57% (n = 233) of the participants were female. The mean age of the nurses was 29.78 years (SD = 6.51) and ranged from 22 to 53 years. The nurses had approximately 7.22 mean years (SD = 6.20) of experience, and approximately half of the nurses were married (n = 216, 53.07%). Most of the nurses in the study (n = 373, 91.65%) had a baccalaureate degree and were working either on rotating shifts (A, B, C or day and night) (n = 287, 70.52%) or on a fixed A shift (n = 120, 29.48%).

The data for this study were collected from hospitals in 3 health care sectors: MOH (n = 145, 35.63%), private (n = 204, 50.12%), and teaching (n = 58, 14.25%). The nurses were recruited from different departments: Approximately 237 (58.23%) were working in general medical and/or surgical departments, 88 (21.62%) were working in intensive care units, and the remaining nurses were working in obstetric, maternity, or pediatric departments. The average daily census for these departments was 19.85 patients (SD = 17.61). In terms of nursing care model, approximately 155 (30%) of the nurses were assigned to total patient care, whereas 174 (42.75%) were assigned to teams. According to the results, 158 (38.82%) of the head nurses adopted a democratic leadership style, 92 (22.60%) were autocratic, and 74 (18.18%) of the head nurses employed a permissive leadership style.

Nurse Burnout

The Jordanian nurses in this study exhibited relatively high levels of both EE (mean = 31.50, SD = 12.84) and DP (mean = 15.24, SD = 6.87) and moderate levels of PA (mean = 32.30, SD = 10.98). Nearly 61% (n = 248) of the nurses scored higher than 27 for EE—the cut point for severe EE³⁴—and approximately 65% (n = 265) of the nurses scored higher than 13 for DP, which is the cut point for severe DP.³⁴ However, 43% (n = 175) of the nurses had low scores (less than 31)—the cut point for nurses’ feelings of low PA,³⁴ which indicates high levels of burnout (Table 3).

MANOVA test revealed a significant main effect for 5 factors on the 3-burnout categories: gender, F_{(3, 403)} = 12.516, P ≤ .01, partial η² = 0.081; work shift, F_{(3, 403)} = 3.644, P ≤ .05, partial η² = 0.026; department type, F_{(3, 403)} = 3.499, P ≤ .01, partial η² = 0.025; nursing care model, F_{(9, 401)} = 2.356, P ≤ .05, partial η² = 0.017; and hospital type, F_{(6, 401)} = 8.735, P ≤ .01, partial η² = 0.061 (Table 1).

Separate analysis of variance (ANOVA) tests were conducted for each individual dependent variable to understand the influence of significant factors on each category of burnout. The study results indicated that the main factors that influence nurses’ feelings of EE were as follows. The first was hospital type (F = 11.10, P ≤ .01), which was highest among the nurses who were working in MOH hospitals. The second was department type (F = 3.77, P ≤ .05), and the highest scores were observed for nurses in intensive care units. The third factor was nurse’s work shift (F = 3.01, P ≤ .05); nurses who were on fixed A shifts had higher EE scores than those who were rotating on different shifts (Table 1). In addition, EE was positively correlated with age (r = 0.111, P ≤ .05) and nursing experience (r = 0.117, P ≤ .05) and negatively correlated with the LEB of participating in decision making (r = −0.110, P ≤ .05) (Table 2).

Nurses’ feelings of DP was significantly associated with department type (F = 5.28, P ≤ .01)—the highest level of DP was observed for intensive care unit nurses—and with gender (F = 3.79, P ≤ .01), as female nurses had higher scores for DP than male nurses (Table 1). In addition, DP was negatively correlated with the 3 categories of leadership empowering behaviors: enhancing the meaningfulness of work (r = −0.132, P ≤ .01), expressing confidence in employees’ performance (r = −0.106, P ≤ .05), and fostering opportunity to participate in decision making (r = −0.101, P ≤ .05) (Table 2).

In relation to PA, the results revealed a significant influence for hospital type (F = 4.11, P ≤ .05) and gender (F = 2.15, P ≤ .05); male nurses exhibited better scores for PA than female nurses (Table 1). In addition, PA was reliably and positively correlated with all categories of LEBs, age, and nursing experience (Table 2).

Although the results show significant correlation values, they are quite low; this could be related to both effect size and sample size. Based on Cohen (1988), the effect size for correlation test in this study ranged from small 0.1 to medium 0.3; hence, results of this study need to be taken with caution.⁴²

Predictors of Burnout

Three separate stepwise regression analyses were performed to identify the predictors of the 3 categories of burnout. All the significant variables associated with each burnout category and all the LEB categories were entered into the regression analysis model in Step 1. However, some variables were omitted such as age, which was correlated with nursing experience, and “overall empowering behaviors,” which encompasses the other behaviors. For EE, the overall model was significant for 4 variables: hospital type, which was responsible for 3% of the variance in EE; nurse’s work shift; providing autonomy; and fostering participation in decision making. Regarding DP, 3 variables were significant predictors of DP: gender, fostering participation in decision making, and department type. These variables accounted for 5.9% of the variance in DP. The regression model for PA was significant for 2 variables: facilitating goal attainment and nursing experience. These variables predicted 8.3% of the total variance in PA (Table 4). LEBs were associated with the 3 categories of burnout. However, the predictive power of the 3 categories was lower than that observed in previous studies.^{8-11,14,20,39}

Limitations and Implications

This study addresses the influence of LEBs, nurses’ work conditions, and nurses’ demographic characteristics on nurses’ feelings of burnout. Although the results of this study are robust, the study has some limitations: Because nonprobability sampling was used, the sample size in some categories was not sufficient to reveal a statistical effect, which may limit the generalizability of the results. Also, both partial η² and R² coefficients show weak effects which may decrease the generalizability of related results; hence, results of this study must be taken with caution.

Future studies are encouraged to use larger and more representative samples for all the analyzed variables to improve the generalizability of the findings.

The results suggest that nurse managers and policy makers should improve nursing work conditions using the following strategies: reduce nurses’ workload through appropriate staffing, improve access to information, distribute resources fairly, provide professional development opportunities, and improve nurses’ leadership skills such as decision making and empowerment. In addition, more experience should not be sufficient to obtain a managerial position in nursing; nursing leadership is an advanced role that requires nurse leaders to have at least a master’s level of education to contribute effectively to shaping the future of health care.⁵⁴ Additional efforts are needed to attract more females to study and practice nursing, and nurse managers should endeavor to enhance the quality of life for working women by offering self-scheduling³² and part-time opportunities and by providing child care services and transportation.

This study raised the issue of burnout as a research priority, and further research is required to assess the unique impact of different factors on burnout, such as work environment, salary, daily distance traveled to work and child care for working mothers. In addition, more clinical trial and intervention studies are suggested to develop programs to reduce work stress as a strategy for attracting nurses, improving quality, and achieving optimal organizational outcomes.

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.

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