December 2008 no white pages.indd Quality of Relationship with Supervisor and Work Exhaustion among Nurses *Unnikammu Moideenkutty,1 Gary Blau,2 Ahmed Al-Mandhari3 املمرضات عند العمل وانهاك مع املشرف نوعية العالقة املندري أحمد ، بلو جاري ، مويدينكتي يونيكامو الطريقة: جمعت ــان. بعم ــفى في مستش العامالت املمرضات عند العمل انهاك في ــرفني املش مع نوعية العالقات ــة أثر لدراس ــص: الهدف: امللخ العمل، انهاك مباشرعلى عكسي تأثير لها واملمرضة املشرف االيجابية بني العالقة أن ــتبيان.النتائج: ظهر اس ــتخدام باس 229 ممرضة من املعطيات اخلالصة: ظهر العائلة. شؤون بالوظيفة وباملهنة والتداخل الوظيفي في والقناعة التعليم ــتوى ومس ــة والتجربة املهنية املؤسس جتربة على وكذلك املمرضات. عند العمل انهاك بتخفيف كبير تاثير لها مع املشرف املتميزة العالقة أن عمان. مهني، والعمليات، النفسية الكلمات: الظاهرة مفتاح SULTAN QABOOS UNIVERSITY MEDICAL JOURNAL NOVEMBER 2008, VOLUME 8, ISSUE 3, P. 275-282 SULTAN QABOOS UNIVERSITY© SUBMITTED - 27TH FEBRUARY 2008 ACCEPTED - 5TH JULY 2008 1Indian Institute of Management Kozhikode, India and Department of Management and College of Commerce & Economics, Sultan Qaboos Uni- versity, Muscat, Sultanate of Oman; 2Temple University, FSBM Hospital, Philadelphia, USA; 3Department of Family Medicine & Public Health and Directorate, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman *To whom correspondence should be addressed. Email: umoideen@squ.edu.om ABSTRACT Objectives: To study the impact of quality of relationships with supervisors, operationalised as leader-member exchange (LMX), on work exhaustion among nurses working for a hospital in Oman. Methods: Data were collected from 229 nurses using a questionnaire. Results: LMX was found to be a significant negative correlate of work exhaustion directly, as well as beyond the con- trolled-for correlates of gender, organisation experience, occupation experience, education level, job satisfaction, occupation satisfac- tion and work interfering with family. Conclusion: A perceived higher quality work relationship with one’s supervisor appears to have a significant impact on reducing perceived work exhaustion among nurses. Keywords: Psychological phenomena and processes; Burnout, professional; Oman. C L I N I C A L A N D B A S I C R E S E A R C H Advances in Knowledge • Leader-member exchange (LMX) was found to impact work exhaustion after controlling for a powerful collective of control variables including: gender, organisation experience, occupation experience, education level, job satisfaction, occupation satisfaction and work interfering with family. • Tested for the impact of LMX on work exhaustion in a non-Western sample. Applications to Patient Care • Work exhaustion and burnout may have negative implications for employee and patient safety in health care organisations. • Improving the quality of work relationship between supervisors and subordinates may help to prevent health care professional burnout. CHANGES AT WORK, INCLUDING GREATER global competition, increased demand for services, increased use of technology, the corporate trend towards mergers, coupled with down-sizing, and greater micromanagement, have collec-tively helped to create a more demanding work envi- U N N I K A M M U M O I D E E N K U T T Y, G A R Y B L AU A N D A H M E D A L - M A N D H A R I 276 ronment for many employees.1, 2 Such changes have resulted in increased levels of employee burnout and exhaustion among various kinds of health care pro- viders in developed Westernised countries, including: doctors,3 nurses,4 radiology technologists,5 direct- care professionals working with the mentally disabled,6 volunteer counsellors caring for the terminally ill and medical technologists.7 Employee exhaustion has not been extensively studied in health care providers out- side Westernised countries, i.e., generally Europe, the United States, Canada, Australia, and Israel.8 The pur- pose of this study is to investigate correlates of work exhaustion for nurses working in a hospital in Oman. D I STI N G UI SH I N G WO R K V E R SUS E MOTI O N A L E X H AUSTI O N Two types of employee exhaustion have been exam- ined in the burnout literature: emotional exhaustion 9 and, more recently, work exhaustion.10 Emotional exhaustion is primarily due to extensive job-required interpersonal contact, while general work exhaustion has wider application to all types of jobs. Moore has defined work exhaustion as: “the depletion of emotion- al and mental energy needed to meet job demands”. Therefore, work exhaustion is meant to encompass emotional exhaustion.11 Given the wide variety of the nurses sampled in this study, it will be argued that work exhaustion was the more appropriate measure to use. Many researchers have argued that emotional or work exhaustion is the key component to experienc- ing burnout,12 as well as the first stage of the burnout process.13, 14 Moore has argued that work exhaustion should be studied as a “stand alone” outcome. Work exhaustion has been empirically linked to higher job turnover intention for information technology professionals.15 The meta-analysis of Lee and Ashforth showed that emotional exhaustion was significantly related to increased turnover intention. R O L E O F L E A D E R - ME MBE R E XC H A N GE I N R E D U C I N G WO R K E X H AUSTI O N Leader-member exchange (LMX) theory16 has argued that supervisors do not use the same style in dealing with all their subordinates, but instead develop dif- ferent types of relationships or exchanges, including low LMX (based strictly on formalised employment contracts and job descriptions) to high LMX (char- acterised by mutual trust, emotional support, respect and reciprocal influence). LMX is typically measured from the subordinate perspective; while supervisor perceived exchange (SLMX) can also be measured.17 Prior research has found many positive outcomes for higher LMX levels, including greater job satisfaction and commitment, stronger performance appraisal rat- ings, and lower stress.18, 19, 20 Work exhaustion is one kind of stress. Most empirical LMX research, includ- ing studies already cited, also focus on Westernised country samples from Europe and the United States (for a recent exception, working with a Chinese work sample, see Aryee & Chen).21 Although less empirical research has directly tested the specific relationship of LMX to work exhaustion, a negative relationship would be expected. Based on the conservation of resources theory of stress of Hobfoll,22 LMX would be conceptualised as a resource condi- tion, where a resource is defined as “any object, condi- tion, personal characteristic or energy that is valued or serves as a means of obtaining resources that are valued”. This theory suggests that work exhaustion can occur when resources, such as LMX, are lost or per- ceived to be inadequate. Related research has found consistent negative relationships between supervi- sor support and emotional exhaustion across differ- ent Westernised country samples of teachers, police officers, social workers, nurses and other health care professionals.23 It seems logical that higher LMX sub- ordinates would have less work exhaustion because potential stressors such as demands and task overload are mitigated by higher levels of support from one’s supervisor.24 Using a large sample of Dutch university employees, Bakker, Demenrouti and Euwena25 found that the quality of the relationship of the subordinate with the supervisor was negatively related to exhaus- tion. This suggests the first hypothesis: H1 – LMX will be negatively related to work exhaustion. C O N TR O L L I N G F O R OTH E R C O R R E L ATE S O F WO R K E X H AUSTI O N Prior research on emotional exhaustion suggests that demographics can affect work exhaustion, including gender (females higher), and work experience (posi- tive). Prior research has not controlled for both organ- isational and professional (occupational) work experi- ence. Although they are related, employees changing organisations generally happens much more frequent- ly than employees changing occupations. For example, Bolles26 has pointed out that the average USA worker under 35 years of age will go job-hunting in a differ- ent organisation every one to three years, while over Q UA L I T Y O F R E L AT I O N S H I P W I T H S U P E R V I S O R A N D WO R K E X H AU S T I O N A M O N G N U R S E S 277 35 year olds will go look for a change of organisa- tions every five to eight years. Bolles also points out that many individuals will change occupations at least three times before exiting the work force. Workload has been found to be positively related to emotional exhaustion. Consistent with the idea of increased education credentials often leading to increased workload responsibilities for health care professionals,27 education level was also controlled for, as a proxy for workload responsibilities. Thus, gender, organisational and professional (occupational) experience, and education level were controlled for in this study. Most prior research on burnout is cross-sectional. Therefore, job satisfaction can also be conceptualised as a negative antecedent or correlate of work exhaus- tion, i.e., lower job satisfaction leading to higher ex- haustion. To the authors’ knowledge, prior studies have not controlled for both job satisfaction and oc- cupational satisfaction. Academic research on occu- pational satisfaction and leaving one’s occupation sug- gests that this is typically a much more difficult type of work transition (versus leaving one’s organisation) due to the greater costs of retraining and human capital in- vestment, disrupted work relationships, and lost time and income, typically associated with occupational change.28, 29, 30 Thus both job satisfaction and occupa- tional satisfaction were controlled for in this study. Role conflict is positively related to emotional ex- haustion. One type of role conflict is work interfering with family,31 which is also a demand on the individu- al. Cordes and Dougherty have argued that individual and organisational demands placed on employees are the key determinants of their exhaustion. Blau and colleagues found that work interfering with family was positively related to work exhaustion for medical technologists working in the USA. Work interfering with family was therefore also controlled for. Cumu- latively, this suggests the following second hypothesis: H2 – LMX will have a significant impact on explaining work exhaustion beyond the controlled for correlates of gender, organisational experience, occupational experience, education level, job satisfaction, occupa- tional satisfaction and work interfering with family. M E T H O D S The sample consisted of nurses working at Sultan Qa- boos University Hospital (SQUH), a large teaching hospital in the Sultanate of Oman. Heads of various nursing departments in the hospital were asked to dis- tribute surveys to the nurses in their departments. As a token of appreciation for completing the survey, a packet of candy was given to each department. A box was provided in the nursing superintendent’s office for submitting completed surveys. Out of 448 surveys dis- tributed, 275 completed surveys were returned, giving a response rate of 61.38%. However, due to missing values, the final sample used for analysis consisted of 229 nurses (51.12%). We were surprised to learn dur- ing survey pre-distribution and working with hospital administration that so many of the nurses were non- Omani or expatriates. Therefore, we decided to con- trol also for expatriate status in the measures section. Most of the expatriate nurses were from India and the Philippines, with a smaller proportion of ethnic Chi- nese Malaysians. Due to the international nature of the nursing and other hospital staff, English was the of- ficial language of the hospital and proficiency in Eng- lish was a requirement of employment. Work exhaustion was measured using a six-item measure based on previous research. Copyright re- strictions and cost associated with the Maslach Burn- out Inventory, as well as survey length constraints and the diversity of nursing grades across shifts sampled, made using this general exhaustion measure more appealing. Subsequent reliability analyses, including item-total statistics (Statistical Package for the Social Sciences, SPSS-PC, version 14), indicated that one item from the work exhaustion measure, “I am often tired or fatigued”, had a lower squared multiple corre- lation with the other five items, and that deleting this item would improve the alpha or internal consistency of the scale. Accordingly, this item was removed and five items were retained. Sample retained items are: “my job demands too much from me”, and “at times I feel like giving up at my job”. These retained items are more consistent with the definition of work exhaus- tion suggested by Moore, “the depletion of emotional and mental energy needed to meet one’s job demands”, while the deleted item focuses more on physical ener- gy. Unless otherwise noted, all multi-item scales used a 6-point response scale, where: 1 = strongly disagree; 2 = disagree; 3 = slightly disagree; 4 = slightly agree; 5 = agree and 6 = strongly agree. Leader-member exchange was measured using Version 6 of the LMX scale, which is a seven item measure and well accepted in the LMX literature. A sample item is: “my supervisor understands my prob- U N N I K A M M U M O I D E E N K U T T Y, G A R Y B L AU A N D A H M E D A L - M A N D H A R I 278 lems and needs”. The control variables were as follows: gender was measured by indicating 0 = male, 1 = female; organisa- tional experience was measured by asking, “you have worked for SQUH for…” (which category): 1 = less than one year, 2 = 1-5 years, 3 = 6-10 years, 4 = 11-20 years, and 5 = more than 20 years; occupational experience was measured by asking, “you have been a nurse for…” and the above same 5 categories were used; expatriate status was measured by asking, “you are”: 0 = Omani, 1 = Expatriate; education level was measured by asking respondents to “check their level of professional quali- fication”, using the following choices: 1 = diploma; 2 = diploma plus post-basic specialisation certificate; 3 = bachelor’s degree, and 4 = masters’ degree. The diplo- ma is the basic qualification for being a nurse. How- ever, the education level attained is also affected by the expatriate status variable. For example, the quali- fication of Omani nurses is a diploma, awarded by the Omani Institute for Health Services, while the Indian nurses working at the hospital would have received a bachelor’s degree based on their training in India. Due to survey constraints, job satisfaction was measured using a three-item measure based on Cammann, Fich- man, Jenkins & Klesh.32 A sample item is: “in general, I like my job”. Occupational satisfaction was measured by creating a parallel three-item measure, again due to survey constraints. A sample item is: “overall, I like working in the nursing profession”. Work interfering with family was measured using the four-item meas- ure developed by Gutek and colleagues. A sample item is: “my work takes up time that I would like to spend with family/friends or just relaxing by myself ”. Beyond these formal control variables, we need to comment on shifts. Shift work research, on Western- ised country samples, has generally shown that nurses on rotating shifts have higher job stress than nurses on fixed shifts. 33, 34 However, in the Omani hospital stud- ied, all nurses were on “permanent rotation”, i.e., eve- ryone worked a few days of night shift, then a morning shift, and then an evening shift and so on. Thus, the current shift data we collected was very temporary. We did not control for shift as part of formally testing Variable Name M SD 1 2 3 4 5 6 7 8 9 10 Gendera 0.92 0.27 (NA)b Organisation Experiencec 2.31 0.95 0.01 (NA) Occupational Experiencec 3.66 0.96 0.05 0.34 (NA) Expatriate Statusd 0.93 0.26 0.05 0.07 0.46 (NA) Education Levele 2.04 0.95 -0.16 -0.01 -0.05 0.21 (NA) Job Satisfaction 4.95 0.84 -0.15 0.04 0.14 0.11 -0.26 (NA) Occupation Satisfaction 5.21 0.71 0.16 0.01 0.19 0.19 -0.20 0.70 (NA) Work Interfering With Family 3.77 1.05 -0.12 -0.06 -0.13 -0.26 -0.04 -0.31 -0.31 (NA) Leader-Member Exchange 5.02 0.67 -0.05 -0.02 -0.02 0.06 -0.08 0.43 -0.47 -0.14 (NA) Work Exhaustion 3.06 1.01 -0.10 -0.07 -0.04 -0.11 0.11 -0.51 -0.50 0.49 -0.36 (NA) Note. N = 229. r > .13 (p < .05); r > .18 (p < .01) both two-tailed a - Gender: 0 = male, 1 = female b - Coefficient alpha in parentheses, NA = not applicable c - Categories are: 1 = less than one year; 2 = 1-5 years; 3 = 6-10 years; 4 = 11-20 years; 5 = more than 20 years d - Expatriate Status: 0 = Omani; 1 = Expatriate e - Education level: 1 = diploma; 2 = diploma plus post-basic specialization certificate; 3 = Bachelor’s degree; 4 = Masters degree Table 1: Means, Standard Deviations, Reliabilities and Correlations for All Study Variables Q UA L I T Y O F R E L AT I O N S H I P W I T H S U P E R V I S O R A N D WO R K E X H AU S T I O N A M O N G N U R S E S 279 H2 because of additional missing data for this variable. However, to check for the potential impact of the cur- rent shift a separate series of t-tests was performed. These tests revealed that the current shift (morning versus evening versus night) did not affect work ex- haustion. R E S U L T S GE N E R A L Table 1 presents the means, standard deviations, scale reliabilities, and correlations for all study variables. In- spection of the scale indicates that nurses were over- whelmingly female expatriates, with high levels of job satisfaction, occupation satisfaction and leader-mem- ber exchange. This sample had prior occupational experience to that with their present employer. All multi-item scale reliabilities were over .70.35 Correla- tion results suggest that increased education level is associated with decreased job satisfaction and occu- pation satisfaction. Job satisfaction and occupation satisfaction, while highly related, show less than 50% overlap (r = .70), and will be retained as distinct vari- ables. Consistent with the LMX literature, job satisfac- tion is positively related to LMX (r = .43). Consistent with the exhaustion literature, job satisfaction is nega- tively related to work exhaustion (r = -.51) and work interfering with family is positively related to work ex- haustion (r = .49). TE STS F O R H Y P OTH E SE S The results in Table 1 support Hypothesis 1(H1), LMX is negatively related to work exhaustion, r = -.36 (p < .01). Hierarchical regression analysis was used to test H2, and the results are shown in Table 2. Controlled-for correlates were stepped into the re- gression equation as follow: Step 1 - gender, organisa- tional experience, occupational experience, education level, and expatriate status; Step 2 - job satisfaction and occupational satisfaction; Step 3 - work interfer- ing with family, and Step 4 - LMX. The results show that LMX results in a very modest but still significant increase. (B = -.18, change in R2 = 1%, p < .05) in ex- plaining work exhaustion, beyond these controlled-for correlates. As such these results support H2. Overall 41% (p < .01) of the variance in work exhaustion was accounted for. D I S C U S S I O N Using a unique sample of nurses in Oman and a pow- erful collective set of control variables, this study found that leader-member exchange (LMX) had a sig- nificant impact on reducing work exhaustion. As not- ed earlier, research testing LMX and work exhaustion variables in non-Western samples is less prevalent. As described earlier, the expatriate nurses came from Variable Entered B Adjusted R2 Change R2 R2 Significant F Change Gender Organisation Experience Occupational Experience Expatriate Status Education Level -0.07 -0.10 -0.01 0.03 0,02 2.00 Job Satisfaction Occupation Satisfaction -.27** -.26** 0.29 0.27 43.77** Work Interfering With Family .34** 0.40 0.11 39.71** Leader-Member Exchange -0.18* 0.41 0.01 4.04* Note. N = 229, * p < .05; ** p < .01 (two-tailed) Table 2: Hierarchical Regression for Explaining Work Exhaustion U N N I K A M M U M O I D E E N K U T T Y, G A R Y B L AU A N D A H M E D A L - M A N D H A R I 280 India, the Philippines and a smaller proportion from Malaysia. To the authors’ knowledge, research has not tested for the impact of LMX on work exhaustion us- ing a research design with as many relevant control variables. Particularly in health care settings, where burnout and work exhaustion are too often found, 36 the importance of a perceived higher quality work re- lationship with one’s supervisor in reducing perceived exhaustion cannot be underestimated. There are some limitations to this study. From a measurement perspective, the high mean levels for the job and occupation satisfaction and LMX variables, while reassuring to the participating hospital, un- doubtedly contributed to lower correlational findings through restriction of range. Survey length constraints necessitated using proxy variables, such as education level for increasing task responsibilities. Future re- search directly testing the relationship of task respon- sibilities to work exhaustion and burnout is needed. Such constraints also necessitated using very short measures of job satisfaction and occupational satisfac- tion. Although adequate reliabilities were found for both measures, testing the robustness of findings us- ing more common job satisfaction measures, such as the Job Diagnostic Survey37 is recommended. As noted earlier, work exhaustion was only par- tially measured, due to cost and survey length, and broader sample applicability issues. The measure of work exhaustion used demonstrated strong internal consistency (alpha = .81) and has been previously used.7 Certainly testing for the impact of LMX on overall burnout and its specific components, emo- tional exhaustion, depersonalisation, and diminished personal accomplishment would be useful. While the Maslach Burnout Inventory or MBI is still the most common measure of overall burnout, and its compo- nents, problems have been noted with the MBI and alternative measures do exist.38 Studying the rela- tionships of LMX to different types of burnout and its component measures is clearly needed in other health care organisation settings. A limitation of the research design is the focus on one demand, work interfering with family. Given more survey space, it would have been desirable to have fo- cused on other demands such as physical and emotion- al work demands. Bakker and colleagues found some support for quality of relationship with one’s supervi- sor significantly interacting with work demands to de- crease work exhaustion, which is consistent with the Demand-Control Model of Karasek.39 Unfortunately, we did not find that LMX interacted with work inter- fering with family to affect work exhaustion. Casting a ‘broader net’ of work demand variables, to test for such interactive effects would have been useful, and is highly recommended for future research. All data was collected at one point in time so that causal inference is limited. In addition, there is a com- mon method variance problem since all data is self- report. Future research testing the impact of LMX on work exhaustion by assessing supervisor-perceived exchange or SMLX40 is also needed. In order to test for the impact of common method variance on our re- sults, we performed the Harman one-factor test.41 If such a test shows that the majority of the covariance between independent and dependent variables loads on one factor, then method variance is a problem. We factor analysed all study variables and found seven factors with eigenvalues over one, including the first factor which only accounted for 28% of the cumulative covariance. Given that our ratio of number of study respondents to total number of items in the scale of 229/27 (almost 9:1) was far over the minimum recom- mended of 5:1 for stable factor analysis,42 we are con- fident that method variance alone is not driving our results. Future research designs working with LMX, work exhaustion, and burnout in health care organisation settings should include other antecedent and outcome variables. For example, Lapierre, Hackett and Taggar recently found that the reverse of work interfering with family (WIF) which is measured as family interfering with work (FIW), has a negative relationship to LMX. Using a longitudinal research design and a sample of Spanish teachers, Carmona, Buunk, Peiro, Rodriguez and Bravo43 found that social comparison and coping style affected self-reported burnout over time. More specifically, the social comparison of downward iden- tification, e.g., “when I see colleagues who are doing worse, I experience fear that my future will be similar”, was positively associated with burnout, while using a direct coping style, e.g., “planning ahead”, was nega- tively associated with burnout. In addition, the impli- cation of work exhaustion and burnout for motivating health care professionals to change their occupations44 makes it important to continue to study in non-West- ernised countries. Though the nurses were of differ- ent nationalities, we grouped them together as expa- triates. Perhaps future studies can examine if there Q UA L I T Y O F R E L AT I O N S H I P W I T H S U P E R V I S O R A N D WO R K E X H AU S T I O N A M O N G N U R S E S 281 are national differences in the relationship between the quality of relationship with a supervisor and work exhaustion. Future studies could also use qualitative methods to uncover the nuances of the relationship between supervisors and employees and their effects on perceived work exhaustion. C O N C L U S I O N As already noted, from a practical implications per- spective, this study shows the importance of a per- ceived higher quality work relationship with the su- pervisor in reducing perceived work exhaustion. Prior research strongly suggests that work exhaustion is the key component to experiencing burnout, as well as the first stage of the burnout process.45 Therefore a high quality work relationship with the supervisor may help to prevent burnout among health care professionals. We were surprised at the high ratio of expatriate to Omani nurses who participated in the study. Staffing requirements for many types of organisations, includ- ing health care, may necessitate the need to hire and retain expatriates.46 Given the overwhelming percent- age of expatriates comprising our sample (93%) we were not able to realistically test the impact of expatri- ate status on work exhaustion. 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