RESEARCH ARTICLE


Effect of Psychological Empowerment on Nurses Burnout



P. Yukthamarani Permarupan1, Abdullah Al Mamun1, *, Naresh Kumar Samy1, Roselina Ahmad Saufi1, Naeem Hayat1
1 Faculty of Entrepreneurship and Business, Universiti Malaysia Kelantan, 16100 Kota Bharu, Malaysia


Article Metrics

CrossRef Citations:
0
Total Statistics:

Full-Text HTML Views: 443
Abstract HTML Views: 279
PDF Downloads: 196
ePub Downloads: 174
Total Views/Downloads: 1092
Unique Statistics:

Full-Text HTML Views: 236
Abstract HTML Views: 182
PDF Downloads: 122
ePub Downloads: 104
Total Views/Downloads: 644



Creative Commons License
© 2019 Permarupan et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: (https://creativecommons.org/licenses/by/4.0/legalcode). This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

* Address correspondence to this author at the Faculty of Entrepreneurship and Business, Universiti Malaysia Kelantan, 16100 Kota Bharu, Malaysia;
Email: abdullah.a@umk.edu.my


Abstract

Objective:

The health industry needs motivated and satisfied nursing staff to provide quality health services to medical tourists, as well as in other sectors. This study aimed to examine the effects of psychological empowerment on the dimensions of burnout among the Malaysian nursing staff, as well as exploring the role of age, gender, experience, and marital status on the perception of burnout dimensions.

Methods:

This survey used a sample of 432 nursing staff, using measures of the perception of empowerment and comparing variables with another measure of burnout, collected via a self-reported questionnaire. Data were analyzed using PLS-SEM. Moreover, the group analysis in PLS-SEM estimated the differences among the nursing staff’s perception of psychological empowerment on burnout factors.

Results:

The findings reveal that psychological empowerment reduces the impact of burnout symptoms. Moreover, gender and age are different for depersonalization by the perception of psychological empowerment among the nursing staff in Malaysia. The Malaysian nursing staff’s marital status influences the relationships between psychological empowerment and depersonalization, as well as emotional exhaustion and personal unfulfillment. Moreover, the experience of the nursing staff influences the perception of personal unfulfillment in a significant manner.

Conclusion:

This study offered important managerial implications, such as considering the nursing staff’s needs according to age, gender, material status, and working experience to address burnout issues of emotional exhaustion, depersonalization, and personal unfulfillment. Moreover, it is important to note that the different factors of burnout are perceived differently by the nursing staff based on their attributes. There is a need to utilize the provision of psychological empowerment needs.

Keywords: Burnout, Empowerment, Malaysia, Survey, Nurses, Psychological empowerment.



1. INTRODUCTION

The demanding nature of the nursing profession is well-known, and the nursing profession has a lot of work demands and stressful work schedules with pressures from patients and caretakers. The demanding nature of nursing job demands physical and emotional resources [1]. The physical and emotional resources when depleted are called burnout which is experienced by Malaysian nursing staff [2]. Burnout has a huge impact on the health industry and nursing staff [3].

The provision of psychological empowerment can reduce the impact of burnout and enable better work performance [4]. Psychological empowerment can reduce burnout symptoms [5]. However, the symptoms of burnout may vary among the nursing staff based on their factors such as age, gender, experience, and marital status [6]. Therefore, it is important to formulate the right policies to reduce burnout effects as the provision of psychological empowerment needs to be managed as higher empowerment can have negative effects [7]. Psychological empowerment has different effects on the nursing staff based on their required and personal factors, such as age, gender, experiences, and marital status [8].

The health industry in Malaysia is mutually run by the public and private sectors. Seventy-five percent of the health services in Malaysia are provided by the public sector [9]. Nevertheless, the cost of the private sector is higher than the public sector in providing health services [10]. Moreover, the health industry in Malaysia wants to become a hub for health travellers from around the world in increasing the global healthcare travellers industry [11]. However, the rising demands in the nature of work and quality of work have affected the current nursing staff in Malaysia in terms of quantity and quality [12]. The shortage of nursing staff in Malaysia is due to high demand which causes stress, job dissatisfaction, and burnout indications [13]. The escalation in attrition among the Malaysian nursing staff is due to stressful working conditions [14]. This study attempted to explore the impact of psychological empowerment on burnout and the effect of the nursing staff’s attributes such as age, gender, experience, and marital status in influencing the burnout symptoms. The differences in the perception of burnout are based on the attributes of the nursing staff in changing the management of the nursing staff to reduce the impact of burnout. This study will expand the literature on managing burnout among nursing staff. The nursing staff has different attributes such as age, gender, experience, marital status, and varying needs for the provision of empowerment. Moreover, the psychological empowerment needs to be managed using the right policies at the workplace because the psychological empowerment of the nursing staff is different based on their factors and impact of burnout symptoms.

The next section is regarding the literature on psycho- logical empowerment, depersonalization, emotional exhaus- tion, and personal unfulfillment. Then, it is followed by the method of this study based on literature review and the hypotheses development. The analysis and results are reported in section 4 and 5, respectively. Section 6 presents the conclusions with future research opportunities and limitations.

2. LITERATURE REVIEW

2.1. Psychological Empowerment

Perception of empowerment provides the necessary resourcefulness in providing necessary conditions of working in life and organizational work-life [5]. Empowerment can motivate an individual to work with zeal and full capacity in achieving organisational goals [15]. The cognitive state of mind that triggers the state of confidence to work with full force termed as psychological empowerment [16]. Psycho- logical is the process of perception on the realities around the individual, and positive perception can lead to empowerment or otherwise.

Spreitzer [17] defined psychological empowerment as the cognition state resulted from the subjective positive trans- formation of perceptions, and an individual starts to work with full dedication and fully immersed in the work environment. Psychological empowerment consists of four structural processes namely meaning, competence, self-determination, and impact [15].

Meaning provides the objective of work and direction for a person’s actions [5]. Organizational objectives and individual objectives can sync in which an individual builds a strong bond based on common objectives and purposes between him or her and the organization [15]. The two sides can emerge as a common purpose that can lead to psychological empowerment [16].

Individual competency is the notion of having a true unbiased opinion of a person’s capacities with the right skills and set of knowledge [15]. This idea is associated with having self-efficacy and believing in oneself [5]. Having a positive belief helps an individual to become more dedicated in completing the task at hand and looking for new opportunities at the workplace [16]. The positive self-evaluation of one’s abilities and having the right abilities can influence an individual to work hard for the organization as the purposes match the individual’s precise capacities in their job performance.

However, having the right skills and objectives that match the organization is not enough. Individuals should be motivated to use their innate skills and objective at hand in performing with the provision of the right environment [16, 18]. Environment enablers are the autonomy and freedom at the workplace to make choices regarding work-related issues. Meaning, competence, and willingness to put the right efforts can empower individuals to build a sense of power and purpose [5]. When individuals motivated at their workplace, they will put more efforts in the right direction as they have the right motivation for the organization [16]. The perception of autonomy and freedom provides opportunities to manipulate and correct work procedures [15]. The impact is the outcome of individual efforts such as having a common purpose and putting the effort with dedication [19]. The positive impact can lead the individual to put more efforts [5].

The difference between high performing and low performing employees is the self-perceived psychological empowerment at the workplace [20]. If the psychological empowerment prevails at large in the organization, the organization can either perform well or vice versa. The general sense of empowerment leads to higher work performance and lower negative feelings towards the work and workplace.

2.2. Depersonalization, Emotional Exhaustion, and Pers- onal Unfulfillment

2.2.1. Depersonalization

People with depersonalization like to keep a distance from the things they do not like and avoid unpleasant events and situations which happen at the workplace. Keeping personal self at a distance from work and not putting real self in work can be termed as depersonalization [3]. People start developing a sense of lacking purpose or aim at the workplace and keeping their true self and efforts away from work [21]. Workers start avoiding work with no sense of responsibility towards their work [22]. These ‘cold’ behavior of nurses are projected to the patients and carers of the patients. Nursing staff lose the purpose of work, avoid work-related responsibilities, and keep the distance from their work [6]. This behavior can lead to no purpose at the workplace and trigger frustration which leads to no work responsibilities.

2.2.2. Emotional Exhaustion

The depletion of resources can be in the form of physical and emotional elements. The lack of resourcefulness grows, which also reduces the interest and effort [23]. People engaged in a work-avoiding attitude as they do not feel resources available to discharge the work responsibilities [21]. These resource depleted attitudes bring the harsh and cold behaviors of the worker towards other workers and patients alike [24]. This drain of resourcefulness causes loss of work and work-related motivations and workers with emotional exhaustion will avoid work-related tasks at the workplace [25]. They will look for new work or work with no work-related objectives.

2.2.3. Personal Unfulfillment

This is the perception of depersonalization and loss of resourcefulness with no or low association to engage in personal accomplishments [25]. Workers will avoid work and delegate the work to others as the work accomplished is not important to them [3]. The work becomes unimportant, and the loss of purpose with the lack of resources in physical and emotional levels can worsen the situation and individuals became prey of no work or personal motivation to accomplish work-related tasks [21, 26].

2.3. Hypotheses Development

2.3.1. Psychological Empowerment and Depersonalization

The development of psychological empowerment can create resources for a worker to work and put more efforts into their work [27]. The perception of depersonalization is associated with hiding true efforts from work and keeping a distance from work-related activities. Therefore, psychological empowerment can reduce depersonalization. When nursing staff have empowerment in work by and working with, full competence and self-determination, they can reduce the possibility of depersonalization [21]. Therefore, the above discussion has led to the following hypotheses:

Hypothesis 1 (H1): Psychological empowerment has a negative effect on depersonalization.

2.3.2. Psychological Empowerment and Emotional Exhaus- tion

The perception of psychological empowerment develops a sense of resourcefulness and triggers the necessary physical and emotional inventories that justify reducing the effects on low personal unfulfillment [28]. Nursing staff with psycho- logical empowerment put more efforts and perception of resourcefulness to reduce the effects of personal unfulfillment [5, 21]. Moreover, psychological empowerment can decrease the effects of emotional exhaustion on the nursing staff. Therefore, the above discussion has led to the following hypothesis:

Hypothesis 2 (H2): Psychological empowerment has a negative effect on emotional exhaustion.

2.3.3. Psychological Empowerment and Personal Unfulfill- ment

The development of resourcefulness and having the capacities to perform the assigned tasks affects the natural tendency developed in individuals to get engaged in the achievements, as well as proving the capacities and honor accomplishments [4, 6, 29]. Personal unfulfillment gets correc- ted with psychological empowerment [3]. Organizational efforts can reduce the negative influence of personal lack of reason and effort putting [30]. Moreover, psychological empowerment can decrease the effects of personal unful- fillment. Therefore, the above discussion has led to the following hypothesis:

Hypothesis 3 (H3): Psychological empowerment has a negative effect on personal unfulfillment.

2.3.4. The Moderating Effect of Age, Gender, Marital Status, and Work Experience

Age is important in terms of nurses’ perception of the things around them. The effect of psychological empowerment on individual depersonalization, emotional exhaustion, and personal unfulfillment is different depending on age [30]. When people age, they change their perception towards the realities around them, realise the necessities of life, and adjust with the environment [4, 23]. Consequently, the age of the nursing staff can affect their opinion on the effects of psychological empowerment on burnout symptoms such as depersonalization, emotional exhaustion, and personal unfulfillment [29]. Therefore, it leads to the following hypothesis:

Hypothesis 4 (H4a): The relationships between psycho- logical empowerment and depersonalization as well as emotional exhaustion and personal unfulfillment are affected by the age of the nurses on their experiences of deperso- nalization, emotional exhaustion, and personal unfulfillment.

Gender is a factor concerning opinion on the realities of the world. Moreover, gender roles are different in societies. For gender, individual work and career preferences are different. The role of gender on individual perception is significant [28]. The outcome of psychological empowerment on individual depersonalization, emotional exhaustion, and personal unfulfillment differs depending on gender [29]. Gender enables people to have a different perception of the realities around them, realise the necessities of life, and adjust with the environment [5]. With the gender differences the individual beliefs and values change as well [22]. Therefore, it leads to the following hypothesis:

Hypothesis 4 (H4b): The relationships between psycho- logical empowerment and depersonalization as well as emotional exhaustion and personal unfulfillment are affected by gender for the experiences of nurses on depersonalization, emotional exhaustion, and personal unfulfillment.

Responsibilities for married and unmarried individuals are not the same [29]. The role of the life changes which affect the people’s perception of different things not only at the workplace but also in life in general [22]. The effects of psychological empowerment on individual depersonalization, emotional exhaustion, and personal unfulfillment differ depending on marital status [6]. Particularly, married individuals have responsibilities at ‘home’ compared to unmarried individuals [21]. Therefore, the perceptions on the psychological empowerment of married nursing staff are different from unmarried nursing staff on the effects of psychological empowerment on burnout symptoms, such as depersonalization, emotional exhaustion, and personal unfulfillment [8, 23]. Therefore, it leads to the following hypothesis:

Hypothesis 4 (H4c): The relationships between psycho- logical empowerment and depersonalization as well as emotional exhaustion and personal unfulfillment are affected by marital status on the experiences of depersonalization, emotional exhaustion, and personal unfulfillment.

The effects of psychological empowerment on individual depersonalization, emotional exhaustion, and personal unful- fillment differ depending on the work experience of the workers [21]. Work experience enables individuals to form and adjust their perception of realities about work-related issues [22]. Individual’s beliefs and values vary in work-related realities [23]. Nursing staff with different working experiences have different opinions about the effects of psychological empowerment on burnout symptoms such as depersonalization, emotional exhaustion, and personal unfulfillment. Therefore, it leads to the following hypothesis:

Hypothesis 4 (H4d): The relationships between psycho- logical empowerment and depersonalization as well as emotional exhaustion and personal unfulfillment are affected by working experiences of the nurses on their experiences of depersonalization, emotional exhaustion, and personal unfulfillment.

3. RESEARCH METHODOLOGY

3.1. Sample Selection

Two tests were performed to evaluate the sample size for this study. This study used the table by Krejcie and Morgan [31] and determined that the sample size must be 378. Moreover, the GPower V2.0 software was also used to determine the sample size using multiple regression statistical analysis by setting the statistical significance at 0.05 with the statistical power at 0.95 for the null hypothesis rejection level and a medium level of effect size at 0.15. The results suggested that the sample size should be 130 samples. The sample frame of this study is the registered hospitals under MOH and the nursing staff who work at the registered hospitals. The list of hospitals retrieved from MHTC website, and this study selected the full-time registered nurses employed by 78 registered hospitals under MOH. A total of 550 survey questionnaires sent, and 467 respondents completed the questionnaires. However, only 432 questionnaires were used for the final analysis as 35 returned questionnaires were incomplete.

3.2. Research Instruments

We used a total of twelve psychological empowerment items adopted from Spreitzer [15]. The estimations of deper- sonalization, emotional exhaustion, and personal unfulfillment were performed using the Maslach’s Burnout Inventory (MBI) with 4, 7, and 4 items, respectively. Maslach et al. [24] reported that the reliability coefficient for the scale is α = 0.91 for emotional exhaustion, α= 0.85 for depersonalization, and α= 0.87 for personal accomplishment.

3.3. Common Method Variance (CMV)

The data collection in social sciences was done using the questionnaires, and this common method has resulted in common method variance and measurement errors [32]. The suggested handling of CMV was after data collection to identify and control the CMV. This study used the single factor Harman’s analysis for testing the CMV [33]. The single factor of this study was the limit of less than 40%; hence, there was no CMV for this study [32].

3.4. Multivariate Normality

This study used Mardia’s online test for the multivariate normality on the web power website to test the multivariate normality of the data [34]. The web power online tool provided the results with skewness and kurtosis coefficients as well as the p-value for the data set. The data considered non-normal if the p-value for the Mardia’s multivariate coefficient is more than 0.05 [35]. The result confirmed that the data were normal.

3.5. Data Analysis Method

PLS-SEM tested the models using two steps, namely measurement and structural model [36]. Cronbach’s alpha (α) and Composite Reliability (CR) are employed to confirm the intern consistency for the constructs. The recommended score for α and CR is 0.70 or above [37]. However, CR is considered a good indicator of internal reliability than α [36].

The Variance Inflation Factor (VIF) represents the inflation of variance due to the presence of multicollinearity within the constructs [37]. The Average Variance Extracted (AVE) value must be 0.50 or above for every construct [36]. The discriminant validity in PLS-SEM was corroborated with cross-loading, Fornell-Larcker, and Heterotrait-Monotrait ratio (HTMT) [36]. The Fornell-Larcker criterion needs to be above 0.700 to provide evidence of discriminate validity. However, HTMT is suggested to discriminate the validity in which the values must be less than 0.90 [36]. The measurement model is represented with r2 that denotes the explanation power of the endogenous variables with the exogenous variables. The effect size (f2) and Q2 are the estimates of the measurement model [37]. The effect size (f2) signifies the effect of each exogenous variable on the endogenous variable. Cohen [38] offered the guidelines for the mean values of f2. The effect sizes of 0.30, 0.15, and 0.02 represent large, medium, and small effect sizes, respectively. The Q2 values of 0.02, 0.15, and 0.35 indicate small, medium, and large predictive relevancies of the model, respectively [36].

Moreover, the Multi-Group Analysis (MGA) in PLS-SEM enables the researchers to identify the different pre-set groups in estimating the differences between the groups based on the pre-defined bases of the group [39]. MGA is efficient to confirm the differences between the groups within the dataset [37]. MGA enables the researchers to track the differences between the structural paths of the multiple groups in the dataset [39]. PLS-MGA determines whether there is any difference in the assessment group and categorises whether the dataset is homogenous or heterogeneous based on the different groups within the dataset [36]. The first step was to categorize the groups based on categorical variables of interest, such as age, gender, or income. Then, the path coefficients of multiple groups analyzed in determining whether the two groups are significantly different from each other based on the guidelines by Henseler et al. [39]. If the difference is significant, the cut-off value of permutation p-values should be less than or equal to 0.10 to establish a significant difference between the groups [37]. The differences that may exist within the dataset based on the characteristics of the sample may not be evident in the aggregated data and path coefficients of the subdivided group data; hence, MGA can be used to determine the differences between the data based on categorical bases [39].

4. RESULTS

4.1. Descriptive Statistics

Table 1 presents the profile of the respondents. The total of female respondents was 85%, and the nursing profession is considered a female profession. For the respondents’ age, the data show that 86% of the respondents were 31 years or more and 14% of them were less than 31. However, the majority of the respondents (68%) were married or once married. Education is the basic requirement in the nursing profession in which 78.9% of the respondents have a college degree in nursing, and 2.1% of them have a master's degree. The minimum qualification in the profession is a certificate. A total of 42.5% of respondents have working experience of the five years or more, and 58% of the respondents have six years or more experience. About 73% of the respondents were Malaysian citizens, and the remaining were non-Malaysians.

4.2. Validity and Reliability

This study followed the recommendations by Hair et al. [36], as shown in Table 2. The α and CR for each construct are more than 0.871 and 0.869, respectively. Cronbach’s alpha value is the measure of inter-correlational approximation on the items for each construct. The Cronbach’s alpha values revealed that 0.963 is the minimum value and the other constructs’ values are above the prescribed limit of 0.70. The Cronbach’s alpha and CR values signify that the constructs are reliable before performing the next analysis. The AVE of all items for each construct must be above 0.50 to achieve convergent validity in approving the uni-dimensionality of each construct [36]. The items display that the constructs have acceptable convergent validity. The loading for every item and cross-loading should be verified to confirm the discriminant validity. The results show that the item loads on particular variables fulfill the notion of discriminant validity. Table 3 shows the results. Another test for discriminant validity is the Fornell-Larcker criterion. The results show that the values are in the acceptable range. Another recommended examination for discriminant validity is the HTMT ratio in which the HTMT values must be 0.90 or fewer to confirm the discriminant validity [37]. Table 3 shows that the study has evidence of discriminant validity.

Table 1. Profile of the respondents.
n % n %
Gender Age
Male 65 15 Less than 30 years of age 57 13.2
Female 377 85 31-41 years of age 228 52.8
Total 432 100 42-52 years of age 95 22
53 and above of age 52 12
Education Total 432 100
Certificate 82 19
Degree 341 78.9
Master 9 2.1 Marital Status
Total 432 100 Single 139 32.2
Married 249 57.6
Divorced 42 9.7
Widowed 2 0.5
Working Experience Total 432 100
less than 2Years 11 2.5
2-5 Years 174 40.3
6-10 Years 154 35.6 Nationality
10-15 Years 47 10.9 Malaysian 315 72.9
16-20 Years 46 10.6 Non-Malaysian 117 28.1
Total 432 100 Total 432 100
Table 2. Reliability analysis.
Variables Number of Items Cronbach’s Alpha Composite Reliability Average Variance Extracted
Psychological Empowerment 12 0.963 0.967 0.713
Depersonalization 4 0.817 0.869 0.628
Emotional Exhaustion 7 0.932 0.945 0.714
Personal Unfulfillment 4 0.963 0.918 0.736
Table 3. Outer loading and cross loadings.
PYE DEP EXU PUF
PYE. Item - 1 0.801 -0.355 -0.448 -0.190
PYE. Item - 2 0.790 -0.343 -0.327 -0.233
PYE. Item - 3 0.856 -0.356 -0.511 -0.247
PYE. Item - 4 0.798 -0.351 -0.472 -0.383
PYE. Item - 5 0.866 -0.345 -0.496 -0.265
PYE. Item - 6 0.731 -0.392 -0.366 -0.365
PYE. Item - 7 0.753 -0.378 -0.445 -0.364
PYE. Item - 8 0.891 -0.387 -0.517 0.265
PYE. Item - 9 0.895 -0.387 -0.516 -0.296
PYE. Item - 10 0.920 -0.411 -0.560 -0.376
PYE. Item - 11 0.831 -0.422 -0.521 -0.370
PYE. Item - 12 0.967 -0.451 -0.550 0.381
DEP. Item - 1 -0.475 0.910 0.406 0.285
DEP. Item -2 -0.416 0.885 0.213 0.295
DEP. Item - 3 -0.076 0.669 0.108 -0.055
DEP. Item - 4 -0.228 0.672 0.408 0.255
EXU. Item -1 -0.609 0.701 0.922 0.355
EXU. Item - 2 -0.448 0.838 0.853 0.334
EXU. Item - 3 -0.539 0675 0.904 0.303
EXU. Item - 4 -0.359 0.623 0.710 0.320
EXU. Item - 5 -0.379 0.737 0.848 0.374
EXU. Item - 6 -0.442 0.698 0.725 0.378
EXU. Item - 7 -0.530 0.715 0.924 0318
PUF. Item - 1 -0.367 0.260 0.838 0.896
PUF. Item - 2 -0.232 0.247 0.732 0.855
PUF. Item - 3 -0.147 0.059 0.568 0.787
PUF. Item - 4 -0.379 0.371 0.416 0.890
Fornell-Larcker Criterion
PSY 0.844
DEP -0.454 0.792
EXU -0.571 0.837 0.845
PUF -0.361 0.308 0.376 0.858
Heterotait-Monotrait Ratios
PSY -
DEP 0.467 -
EXU 0.587 0.927 -
PUF 0.360 0.362 0.374

4.3. Path Analysis

The adjusted r2 value for the three paths, namely psycho- logical empowerment and depersonalization, psychological empowerment and emotional exhaustion, and psychological empowerment and personal unfulfillment, are 20%, 32%, and 12%, respectively. The result explains that 20 per cent of the variance in depersonalization can be explained by psycho- logical empowerment as an input variable. Moreover, 32% per cent of the variance in emotional exhaustion can be explained by psychological empowerment as an input variable, and 12 per cent of the variance in personal unfulfillment can be explained by psychological empowerment as an input variable. The f 2 values for psychological empowerment on deper- sonalization, emotional exhaustion, and personal unfulfillment are 0.260, 0.485, and 0.150, respectively. The effect of psychological empowerment on emotional exhaustion is large, whereas the effects on depersonalization and personal unfulfillment are small. The predictive relevance (Q2) values for the part of the model are 0.100, 0.212, and 0.079 for depersonalization, emotional exhaustion, and personal unfulfillment, respectively. The predictive relevance for personal unfulfillment is small, depersonalization is medium, and emotional exhaustion is medium.

Table 4 shows the standardized path coefficients, t-values, and significance level. The path coefficient values for psychological empowerment on depersonalization is β = -0.454 and p = 0.000, which provide the supports to accept H1. The result shows that the effect of psychological empowerment on the depersonalized type of burnout is negative but significant. The path coefficient forms psychological empowerment on emotional exhaustion which is β = -0.571 and p = 0.000, indicating a negative and significant effect of psychological empowerment on emotional exhaustion. Hence, H2 is supported. The path coefficient for psychological empower- ment on personal unfulfillment is β = -0.361 and p = 0.000. The effect of psychological empowerment on personal unfulfillment perception is negative and significant which supported H3. Table 4 shows the results of path coefficients.

4.4. Multiple Group Analysis

Multiple group analyses were performed to compare the results for different groups based on age, gender, marital status, and work experience. One non-parametric test was utilized to evaluate the differences in the key relationship between the model based on the characteristics of the sample, such as age, gender, marital status, and work experiences (Table 5). Table 6 shows the path values for two groups with the differences within the groups and p-values as recommended by Henseler et al. [39]. PMGA represents the p-values obtained by the use of multiple group analysis of PLS-SEM as the measure of significant difference among the groups [39].

Table 4. Hypothesis testing.
Hypothesis Coefficient t-values Sig. r2 f2 Q2 Decision
H1 PYE → DEP -0.454 13.910 0.000 0.20 0.260 0.100 Supported
H2 PYE → EXT -0.571 20.550 0.000 0.32 0.485 0.212 Supported
H3 PYE →PUF -0.361 9.099 0.000 0.12 0.150 0.079 Supported
Table 5. Multiple group comparisons based on age.
Young Old
β t-values Sig. β t-values Sig. Difference PMGA
PYE →DEP -0.428 9.270 0.000 -0.754 15.908 0.000 0.326 1.000
PYE →EEX -0.643 18.125 0.000 -0.641 13.277 0.000 0.002 0.512
PYE →PUF -0.488 7.595 0.000 -0.487 8.368 0.000 0.001 0.506
Table 6. Multiple group comparison based on Gender.
Male Female
β t-values Sig. β t-values Sig. Difference PMGA
PYE →DEP -0.636 9.980 0.000 -0.443 13.195 0.000 0.193 0.995
PYE →EEX -0.571 7.189 0.000 -0.578 17.597 0.000 0.007 0.480
PYE →PUF -0.401 2.328 0.000 -0.350 7.379 0.000 0.052 0.737
Table 7. Multiple group comparison based on marital status.
Married Unmarried
β t-values Sig. β t-values Sig. Difference PMGA
PYE →DEP -0.509 9.796 0.000 -0.388 9.630 0.000 0.121 0.964
PYE →EEX -0.728 18.587 0.000 -0.493 13.236 0.000 0.236 1.000
PYE →PUF -0.578 10.889 0.000 -0.227 2.621 0.005 0.350 1.000
Table 8. Multiple group comparison based on experience.
Low Experience High Experience
β t-values Sig. β t-values Sig. Difference PMGA
PYE →DEP -0.434 8.714 0.000 -0.431 6.930 0.000 0.003 0.506
PYE →EEX -0.622 14.877 0.000 -0.578 8.860 0.000 0.044 0.711
PYE →PUF -0.430 8.724 0.000 -0.654 19.346 0.005 0.224 1.000

4.4.1. Effects of Age on the Groups

The results of two groups based on the age from the sample confirmed that age has a significant difference in the relationship between psychological empowerment and depersonalization among the nursing staff in Malaysia. The age difference does not affect the relationships between psycho- logical empowerment and emotional exhaustion as well as psychological empowerment and personal unfulfillment.

4.4.2. Effects of Gender on the Groups

The results of the groups based on gender established to have a significant difference in the relationship between psychological empowerment and depersonalization among the nursing staff. Gender makes no difference for the relationships between psychological empowerment and emotional exhaus- tion as well as psychological empowerment and personal unfulfillment.

4.4.3. Effects of Marital Status on the Groups

The results showed that there is a significant difference between the groups of nurses who are married and unmarried. The relationship between psychological empowerment and depersonalization among the nursing staff differs between the married and unmarried nursing staff. Moreover, the rela- tionship between psychological empowerment and emotional exhaustion also varies between married and unmarried nursing professionals. Besides that, the relationship between psycho- logical empowerment and personal unfulfillment varies among the nursing staff significantly according to their marital status (Table 7).

4.4.4. Effect of Experience on the Groups

The difference among the nursing staff based on work experiences shows that there is a statistically significant difference in the relationship between psychological empower- ment and personal unfulfillment. However, there is no statistically significant difference among the nursing staff based on their work experiences for the relationships between psychological empowerment and depersonalization, as well as psychological empowerment and emotional exhaustion among the nursing staff (Table 8).

5. DISCUSSION

Nurses require empowerment at the workplace, which addresses the burnout types, namely depersonalization, emo- tional exhaustion, and personal unfulfillment. Psychological empowerment can negatively and significantly affect deper- sonalization, emotional exhaustion, and personal unfulfillment in which the nurses in Malaysia can manage their burnout using the psychological empowerment at the workplace. Therefore, this study supported H1, H2, and H3. Psychological empowerment can affect emotional exhaustion (f 2 = 0.212) with medium effect, followed by psychological empowerment is depersonalization and the effect size (f 2 = 0.100) represents a medium effect, and psychological empowerment has a small effect size on personal unfulfillment (f 2 = 0.079) (Table 5). The results are similar to the results by Laschinger et al. [40] and Guo et al. [7]. It is revealed that the effect of psychological empowerment on depersonalization is medium that is less than the effect on emotional exhaustion. On the other hand, the effect of psychological empowerment is small on personal unfulfillment. The results also matched the results by Guo et al. [7]. The provision of psychological empowerment is effective in reducing the effects of emotional exhaustion, which is a critical part of the burnout conceptualization.

Finally, this study evaluated the differences in age, gender, marital status, and work experience among the nurses for the perception of burnout symptoms. The results revealed that the impact of psychological empowerment on depersonalization occurred among the young nursing staff than the old nursing staff. However, age has no difference in the relationship between psychological empowerment and emotional exhaus- tion as well as psychological empowerment and personal unfulfillment among the nursing staff in this study. The results revealed that the provision of psychological empowerment is effective for young nurses to reduce depersonalization. The results showed that the differences of gender can affect the relationship between psychological empowerment and deper- sonalization, and there is no difference of gender is affecting the relationships between psychological empowerment and emotional exhaustion as well as psychological empowerment and personal unfulfillment. The result showed that the provision of psychological empowerment is an effective tool to address the issue of depersonalization among women nursing staff. The results revealed that the differences in marital status can affect the relationships between psychological empower- ment and depersonalization, psychological empowerment and emotional exhaustion, as well as psychological empowerment and personal unfulfillment. The results confirmed that the provision of psychological empowerment had addressed emo- tional exhaustion, depersonalization and personal unfulfillment of married nursing staff. The result shows that the differences of experience can affect by the relationship between psychological empowerment and personal unfulfillment, and there is no difference of experience in affecting the relationship between psychological empowerment and emotional exhaustion as well as psychological empowerment and depersonalization. The results highlighted that the provision of psychological empowerment reduced the effects of personal unfulfillment among more experienced nursing staff. The results matched the results by Laschinger et al. [40].

CONCLUSION

Nursing is a noble profession, and a nation’s health will be at stake if the nursing staff are not happy in performing their responsibilities. Nursing has been declared as the most difficult profession in terms of demand and pressures [2]. The Malaysian health system faces tremendous pressure from patients and their carers, and the nursing staff are facing burnout symptoms and leaving the industry in great numbers. Moreover, Malaysia wants to become a health care destination for international patients, which adds to the pressures. The demanding nature of the health industry is a big concern in which management should make necessary arrangements to retain the nursing staff. One of the options is to provide the necessary psychological empowerment to prevent and ameliorate burnout symptoms.

The results of this study revealed that the burnout among the nursing staff could be tackled using the provision of psychological empowerment. Psychological empowerment can reduce the impact of perceptions like depersonalization, emotional exhaustion, and personal unfulfillment. The hospital industry needs to provide the meaning for work by promoting the use of nursing competence with self-determination to reduce the negative perception among the nursing staff so they can work better [29].

Managers from the healthcare industry must provide necessary empowerment to the staff nurses in reducing work-related issues like workload and maintaining good working relationships with colleagues. Moreover, it provides the informal power that facilitates their work. Besides that, better working conditions at the workplace can reduce burnout symptoms. The management staff of the nursing industry in Malaysia must consider the age, gender, experience, and marital status in investigating the nurses’ burnout experiences. The effect of psychological empowerment on burnout symptoms is high for emotional exhaustion, medium for depersonalization, and small for personal unfulfillment. The policies need to focus on the progress in improving psychological empowerment and reducing the negative effects of burnout symptoms. The management of the health industry needs to explore the role of marital status as it can affect the nurses’ opinions on burnout symptoms. The enhanced psychological empowerment can reduce the effect of burnout among the nursing staff so they can provide better service to the local and foreign patients [10]. The increased influx of medical tourists can be tackled with motivated and psychological empowered nurses so that the country can earn foreign exchange [10].

In conclusion, the health industry management needs to focus on strategies to handle the burnout symptoms using psychological empowerment at the workplace [1]. However, the management needs to keep in mind that the roles of psychological empowerment on burnout symptoms are not the same according to the nursing staff’s attributes such as age, gender, marital status, and work experience. It will add value if the nursing staff is considered based on attributes such as age, gender, marital status, and work experiences.

Furthermore, professional training and communication skills of nursing managers can help them to deliver the cognition of psychological empowerment to their nursing staff. Nursing staff’s needs for psychological empowerment are different according to their age, gender, marital status, and work experience. The need for psychological empowerment can reduce the burnout effects among the nursing staff.

There are two major limitations in this study. This study is based on self-reported survey method which leads to biases as the respondents describe their perceptions rather than the facts; it leads to subjectivity and potential biases in the responses [32]. The study adopted a cross-sectional stance due to time and cost constraints. Future studies should adopt a longitudinal approach to collect data over a period of time from the nursing and management staff. Moreover, the explorative method of inquiry can be applied to understand the effectiveness of psychological empowerment in addressing the burnout symptoms. Effective work management and empowering work design can reduce the impact of stress on the nursing staff so they can work effectively.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

This study is approved by Centre for Postgraduate Studies Universiti Malaysia Kelantan.

HUMAN AND ANIMAL RIGHTS

Not Applicable.

CONSENT FOR PUBLICATION

Verbal consent was given by all the participants.

AVAILABILITY OF DATA AND MATERIALS

Not Applicable.

FUNDING

None.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

REFERENCES

[1] Garrosa E, Moreno-Jiménez B, Rodríguez-Muñoz A, Rodríguez-Carvajal R. Role stress and personal resources in nursing: a cross-sectional study of burnout and engagement. Int J Nurs Stud 2011; 48(4): 479-89.
[2] Schaufeli WB. The balance of giving and take: toward a social exchange model of burnout. Int Rev Soc Psychol 2006; 19: 87-131.
[3] Maslach C. Engagement research: Some thoughts from a burnout perspective. Eur J Work Organ Psychol 2011; 20(1): 47-52.
[4] Maslach C, Leiter MP. Understanding the burnout experience: recent research and its implications for psychiatry. World Psychiatry 2016; 15(2): 103-11.
[5] Loemo K. Admasu, B. and Mirkuzie, W., Determinants of Quality of Work Life among Nurses Working in Hawassa Town Public Health Facilities, South Ethiopia: A Cross-Sectional Study. Nurs Res Pract 2017; 1-11.
[6] Long CS, Kowang TO, Ping TA, Muthuveloo R. Investigation on the impact of job stressors on nurses in Malaysia. Asian Soc Sci 2014; 10(4): 67-77.
[7] Guo J, Chen J, Fu J, Ge X, Chen M, Liu Y. Structural empowerment, job stress and burnout of nurses in China. Appl Nurs Res 2016; 31(1): 41-5.
[8] Rudman A, Gustavsson P, Hultell D. A prospective study of nurses’ intentions to leave the profession during their first five years of practice in Sweden. Int J Nurs Stud 2014; 51(4): 612-24.
[9] Permarupan YP, Al-Mamun A, Saufi RA. Quality of work life on employee job involvement and affective commitment between the public and private sector in Malaysia. Asian Soc Sci 2013; 9(7): 268-78.
[10] Tang CF, Tan EC. Tourism-led growth hypothesis in Malaysia: Evidence-based upon regime shift co-integration and time-varying Granger causality techniques. Asia Pac J Tour Res 2015; 20(1): 1430-50.
[11] Aniza I, Aidalina M, Nirmalini R, Inggit MCH, Ajeng TE. Health tourism in Malaysia: strength and weaknesses. Jabatan Kesihatan Masyarakat 2009; 15(1): 7-15.
[12] Ahmad N, Oranye NO. Empowerment, job satisfaction and organizational commitment: a comparative analysis of nurses working in Malaysia and England. J Nurs Manag 2010; 18(5): 582-91.
[13] Aigbogun O, Yassin SN, Shoukat Z. A model for accelerating the growth of health care tourism in Malaysia. J Bus Econ 2013; 4(2): 169-79.
[14] Emilia ZA, Noor HI. Work-related stress and coping: A Survey on Medical and Surgical nurses in a Malaysian teaching hospital. Jabatan Kesihatan Masyarakat 2007; 13: 55-66.
[15] Spreitzer GM. Psychological empowerment in the workplace: Dimensions, measurement, and validation. Acad Manage J 1995; 38(5): 1142-465.
[16] Yiing LH, Ahmad KZB. The moderating effects of organizational culture on the relationships between leadership behavior and organizational commitment and between organizational commitment and job satisfaction and performance. Leadersh Organ Dev J 2009; 30(1): 53-86.
[17] Spreitzer GM. Taking Stock: A review of more than twenty years of research on empowerment at work.Handbook of Organizational Behavior 2008; 54-73.
[18] Kleiner S, Wallace JE. Oncologist burnout and compassion fatigue: investigating time pressure at work as a predictor and the mediating role of work-family conflict. BMC Health Serv Res 2017; 17(1): 639.
[19] John W N, Cavanagh AM. Development of an international tool to measure nurse job satisfaction by testing the Healthcare Environment Survey beyond Jamaica and the United States to Scotland: A cross sectional study utilizing exploratory factor analysis 2018.
[20] Yagil D, Luria G, Gal I. Stressors and resources in customer service roles: Exploring the relationship between core self-evaluations and burnout. Int J Serv Ind Manage 2008; 19(5): 575-95.
[21] McVicar A. Workplace stress in nursing: a literature review. J Adv Nurs 2003; 44(6): 633-42.
[22] Manojlovich M, Laschinger H. The Nursing Worklife Model: extending and refining a new theory. J Nurs Manag 2007; 15(3): 256-63.
[23] Meng L, Liu Y, Liu H, Hu Y, Yang J, Liu J. Relationships among structural empowerment, psychological empowerment, intent to stay and burnout in nursing field in mainland China-based on a cross-sectional questionnaire research. Int J Nurs Pract 2015; 21(3): 303-12.
[24] Maslach C, Jackson SE, Leiter MP. MBI: The Maslach Burnout Inventory: Manual 1996.
[25] Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol 2001; 52: 397-422.
[26] Riedl EM, Thomas J. The moderating role of work pressure on the relationships between emotional demands and tension, exhaustion, and work engagement: an experience sampling study among nurses. Eur J Work Organ Psychol 2019; 28(3): 414-29.
[27] Orgambídez-Ramos A, Borrego-Alés Y. Empowering employees: Structural empowerment as an antecedent of job satisfaction in university settings. Psychol Thought 2014; 7(1): 28-36.
[28] Khamisa N, Peltzer K, Oldenburg B. Burnout in relation to specific contributing factors and health outcomes among nurses: a systematic review. Int J Environ Res Public Health 2013; 10(6): 2214-40.
[29] Siegal M, McDonald T. Person-organization value congruence, burnout, and diversion of resources. Person Rev 2004; 33(3): 291-301.
[30] Adriaenssens J, De Gucht V, Maes S. Determinants and prevalence of burnout in emergency nurses: A systematic review of 25 years of research. Int J Nurs Stud 2015; 52(2): 649-61.
[31] Krejcie RV, Morgan DW. Determining Sample Size for Research Activities. Educ Psychol Meas 1970; 30: 607-10.
[32] Podsakoff PM, MacKenzie SB, Podsakoff NP. Sources of method bias in social science research and recommendations on how to control it. Annu Rev Psychol 2012; 63: 539-69.
[33] Harman HH. Modern Factor Analysis 3rd ed. 1976.
[34] Peng DX, Lai F. Using partial least squares in operations management research: a practical guideline and summary of past research. J Oper Manage 2012; 30(6): 467-80.
[35] Cain MK, Zhang Z, Yuan K-H. Univariate and multivariate skewness and kurtosis for measuring nonnormality: Prevalence, influence and estimation. Behav Res Methods 2017; 49(5): 1716-35.
[36] Hair JF, Ringle CM, Sarstedt M. Editorial-partial least squares structural equation modeling: rigorous applications, better results, and higher acceptance. Long Range Plann 2014; 46(1-2): 1-12.
[37] Chin WW. How to write up and report PLS analyses.Handbook of Partial Least Squares 2010.
[38] Cohen J. Statistical Power Analysis for the Behavioral Sciences 1988.
[39] Henseler J, Ringle C, Sinkovics R. The use of partial least squares path modeling in international marketing.2009.
[40] Laschinger HKS, Wong CA, Grau AL. Authentic leadership, empowerment and burnout: a comparison in new graduates and experienced nurses. J Nurs Manag 2013; 21(3): 541-52.