key: cord-0924096-y4boz8xx
authors: Ma, Ying; Faraz, Naveed Ahmad; Ahmed, Fawad; Iqbal, Muhammad Khalid; Saeed, Umair; Mughal, Muhammad Farhan; Raza, Ali
title: Curbing nurses' burnout during COVID‐19: The roles of servant leadership and psychological safety
date: 2021-08-31
journal: J Nurs Manag
DOI: 10.1111/jonm.13414
sha: 83ea8ec02b1e956a78e1f1fff3527e388355d85c
doc_id: 924096
cord_uid: y4boz8xx

AIMS: This study examines the role of servant leadership through the mechanism of psychological safety in curbing nurses' burnout during the COVID‐19 pandemic. BACKGROUND: During the COVID‐19 pandemic, studies have shown an increased level of stress and burnout among health care workers, especially nurses. This study responds to the call for research to explore the mechanisms of servant leadership in predicting nurses' burnout by employing the perspective of conservation of resources theory. METHODS: Through a cross‐sectional quantitative research design, data were collected in three waves from 443 nurses working in Pakistan's five public sector hospitals. Data were analysed by employing the partial least squares path modelling (PLS‐PM) technique. RESULTS: Servant leadership (β = −0.318; 95% CI = 0.225, 0.416) and psychological safety (β = −0.342; CI = 0.143, 0.350) have an inverse relationship with nurses' burnout and explain 63.1% variance. CONCLUSIONS: Servant leadership significantly reduces nurses' burnout, and psychological safety mediates this relationship. IMPLICATIONS FOR NURSING MANAGEMENT: Human resource management policies in health care must emphasize training nursing leaders in servant leadership behaviour.

psychological outcomes. The suffering and death of patients bring traumatic experiences. Besides being the front-line fighters, nurses are at a high risk of exposure to the disease (Domínguez-Salas et al., 2021) . Such negative emotions at the workplace may lead to nurses' burnout (Liu & Aungsuroch, 2019) . Burnout at the workplace is defined as "the employees' negative response to chronic work stressors" (Vullinghs et al., 2018) . Burnout is associated with emotional dysfunction, cognitive impairment, physical morbidity, fatigue, and sleep impairment (Schaufeli et al., 2009) . Likewise, it is also linked to socio-economic ramifications such as job dissatisfaction, increased turnover, reduced productivity at work (García-Sierra et al., 2016) , and withdrawal from the job in the shape of absenteeism or even intention to leave the nursing profession (Theodosius et al., 2021) . A report published by the World Health Organization (2020) highlighted that to reach Sustainable Development Goal number three (health and well-being), the world will need an additional nine million nurses and midwives by the year 2030. The significant shortages of nurses are in South East Asia and Africa. In the context of Pakistan, there was severe shortage of nurses, 1.3 million, even before the COVID-19 pandemic. Thus, the factors that can subside burnout among nurses during COVID-19 are an exciting avenue to be explored.

Literature has identified several predictors of burnout, that is, inadequate social support, organizational politics, bullying at the workplace, employer unfairness, and leadership (Hildenbrand et al., 2018) .

Leadership and burnout have been studied for transformational, ethical, authentic, and transactional leadership styles (Arnold et al., 2017; Hildenbrand et al., 2018; Laschinger et al., 2013; Lee et al., 2019) .

However, servant leadership has been given less attention in terms of its impact on work-related burnout. Greenleaf (1977) coined the term servant leadership as an approach to leadership that emphasizes developing followers to their fullest potential in self-motivation, task effectiveness, and community service. Despite receiving acceptable criticism regarding a distinctive theory (Bradley, 1999) , servant leadership has gathered a reasonable share in research publications (Eva et al., 2019) . Servant leadership is all about philosophy and practices that improve individuals' lives and focus more on creating better organizations and a caring world (Martin, 2018) . In addition, servant leaders are concerned about emotional healing, altruism, and creating a better relationship with their followers. It is posited that these humanistic characteristics of servant leaders would be negatively associated with nurses' burnout during the COVID-19 pandemic.

First, this study contributes by responding to suggestions of scholars to explore the intervening variables that serve as a mechanism in predicting the relationship between servant leadership and employees' outcomes (Faraz et al., 2019) . The mechanism through which servant leadership influences nurses' burnout needs further research as the matter is yet not sufficiently clear. Chughtai (2016) found that servant leadership enhances the employees' psychological safety, which mediates feedback and voice behaviours. Second, responding to the call for research (Eva et al., 2019) , this study investigates the relationship between servant leadership and nurses' burnout during the COVID-19 pandemic in the backdrop of the conservation of resources (COR) theory. Third, it responds to the call by Edmondson (2014) for further research on antecedents and outcomes of psychological safety and is the first study to explore the mediating role of psychological safety between servant leadership and nurses' burnout relationship.

Leaders are responsible for employees' work-related well-being by balancing their job resources and demands. A nurse servant leader seeks to determine the needs of their staff and frequently asks how they can support the team to resolve problems and promote their personal growth (Best, 2020) . Servant leaders can effectively deal with job burnout among nurses because such leaders mainly focus on followers' well-being (Coetzer et al., 2017) . This support and positive association of leaders towards employees compels them to accomplish a meaningful outcome beneficial not only for the individuals but also for the organizations and the community (Coetzer et al., 2017) .

Health care organizations strive to meet increased workload during the COVID-19 pandemic, which has led to increased job burnout of the nurses. Job burnout, a stress reaction, is identified with three dimensions: emotional exhaustion, cynicism, and professional efficacy (Maslach et al., 1996; Xie et al., 2020) . Emotional exhaustion is the result of resource depletion, and an individual feels the loss of control over what happens in his/her life. This emotional exhaustion leads to demotivation among employees (Maslach et al., 1996) . Cynicism distrusts others' motives, while professional efficacy is a lack of interest in one's work (Leiter, 1997) . The impact of job burnout is linked to both positive and negative outcomes. Scholars argued that burnout is associated with positive job performance, health, and negative behaviours such as absenteeism, job dissatisfaction, and higher turnover (Hunsaker, 2019) .

Conservation of resources (COR) theory holds the tenet that individuals endeavour to acquire, protect, and foster those resources they centrally value. It comprehends and predicts work-related stress, that is, burnout within specific work settings and cultures. COR posits that the occurrence of stress among individuals is subject to three conditions: (a) when an individual's essential resources are threatened with loss, (b) when critical resources are lost, and (c) when an individual fails to obtain the critical resources following significant effort (Hobfoll et al., 2018) . Therefore, to overcome this threat of loss of resources or the loss of existing resources, individuals in response acquire and conserve resources for survival. These valuable resources for survival include social bonding, energy, and personal strength (Usman et al., 2020) . To ensure survival and respond to stress, individuals employ relationships as critical resources. Divya and Suganthi (2018) concluded that servant leaders reduce employee burnout. This study argues that servant leadership is a critical organizational resource that reduces nurses' burnout. Servant leaders emphasize more one-to-one communication with subordinates. By instilling motivation and self-efficacy, servant leaders try to bring out the best in their followers, encouraging them to transform into servant leaders (Babakus et al., 2010) . In this process, they act as role models for followers by supporting risk-taking and proactive behaviour, encouraging them to speak about their concerns and intentions for others' well-being. So, the servant leaders serve the nurses by acting as an organizational resource, which increases their motivation and eagerness to learn and grow. Thus, nurses supervised by servant leaders positively perceive the leaders as an essential resource during the time of crisis like COVID-19. Therefore, grounded on the COR theory and on empirical evidence, we propose the following:

Hypothesis 1. Servant leadership is negatively related to nurses' burnout.

Psychological safety is an individual's perception concerning the consequences of risk-taking, others' well-being, and admitting mistakes (Erkutlu & Chafra, 2019) . It refers to a situation where employees believe that they will not be punished for raising their voices and ideas, reporting mistakes, and sharing opinions (Edmondson & Lei, 2014) . Leaders can play a critical role in employees' psychological safety (Dirik & Seren Intepeler, 2017) by dealing with the challenges of emotional exhaustion, cynicism, and professional efficacy. There is a call for the scholarship to examine the role of servant leadership in relation to psychological safety and burnout (Eva et al., 2018) . Servant leaders facilitate nurses by creating a safe working environment where employees' mistakes are tolerated. A servant leader is characterized by empathy, healing, awareness, persuasion, stewardship, and commitment to subordinates' growth (Sherman, 2019) . Such leaders focus on encouragement by empowering and lifting those who work for them (Karatepe et al., 2019) : always look after staff's needs and work for the self-development of subordinates (Lee et al., 2020) . So, a servant leader naturally safeguards the psychological safety of the nurses. Such leaders follow the open communication approach.

Leaders' accessibility to employees sends signals that it is safe to approach them. This high-quality interpersonal relationship between a leader and his/her subordinate facilitates the introduction of psychological safety (Erkutlu & Chafra, 2019) .

atmosphere of psychological safety , which helps nurses be less prone to work-related stress, emotional exhaustion, cognitive impairment, and interpersonal risk effects at the workplace (Erkutlu & Chafra, 2019) .

Following COR theory, we argue that servant leaders show empathy, availability, and concern for their followers. These characteristics of servant leaders are perceived as a resource by the nurses and thus develop a sense of psychological safety ). Nurses with a higher level of psychological resources, including psychological safety, will be motivated to invest those resources in coping with the workplace's challenges like burnout. Based on the above discussion, we posit that psychological safety acts as a mediator between a servant leadership and nurses' burnout ( Figure 1) . Therefore, the following are hypothesized: patients. Criteria for selecting hospitals include (i) employing at least 500 nurses, (ii) one from the four provincial capitals, and one from the capital city of Pakistan. The authors approached the HR department of the selected hospitals, explained the purpose of the study, ensured the participants' privacy, and sought approval for data collection. After getting approval from the HR department for data collection, a written request was made to provide the list of nurses' names and email addresses. The final consolidated list containing 3579 nurses from five hospitals was sorted alphabetically for every hospital. By employing systematic random sampling, every fourth nurse was shortlisted as a potential respondent.

Researchers designed three separate survey forms to capture independent, mediator, and dependent variables on Google docs. The F I G U R E 1 Theoretical model questionnaires were administered online separately at three time periods during February to March 2021 with a temporal separation of 10 days to overcome likely common method bias (Podsakoff et al., 2012) . At the first time point, the questionnaire was administered to 895 nurses, wherein they were requested to provide demographic data and rate the servant leadership of their supervi- The summarized demographics of the respondents are presented in Table 1 . Psychological safety was evaluated with a three-item scale adapted by Detert and Burris (2007) from the original measure of psychological safety by Edmondson (1999) . A sample item includes the following: "In this hospital, it is safe for me to make suggestions."

Burnout was assessed with 16 items from the Maslach Burnout Inventory-General Survey (Maslach et al., 1996) , commonly used with total score of the three dimensions, namely, exhaustion, cynicism, and professional efficacy. A sample item is "I feel emotionally drained from my work."

Analysis of this study was performed by introducing the partial least squares path modelling (PLS-PM) technique with the Smart-PLS 3.3.3 software. The study in hand preferred the PLS-PM method because of multiple reasons. First, it facilitates the analysis of multifaceted models comprising several constructs, indicators, and relationships (Ringle et al., 2018) . Second, due to its dominance over other techniques while analysing mediation; third, it is particularly appropriate for prediction-oriented studies (Zhao, Ahmed, Iqbal, et al., 2020) , for instance, nurses' burnout. Fourth, it is equipped with the latest statistical tools, including confidence intervals for hypothesis testing, effect size to know the relative contribution of predictor constructs, graphs for moderation analysis, and heterotrait-monotrait (HTMT) ratio for discriminant validity. Lastly, comparatively, it offers better statistical power. PLS-PM comprises a two-stage approach for analysis (Hair et al., 2020) , and for these reasons, its use has increased over the years in management research Zhao, Ahmed, Iqbal, et al., 2020) in recent years.

Recently scholars have advanced confirmatory composite analysis (CCA) as a systematic methodological procedure for evaluating PLS-PM measurement models (Hair et al., 2020) . All other constructs have been treated as reflective lower-order except burnout which is treated as higher-order reflective-reflective. The subsequent steps perform the CCA:

In the first step of CCA, the evaluation of the items' loadings was calculated. Under a two-tailed test, an item is treated as signification if it has a loadings value above 0.708 and a t statistic above AE1.96 (Hair et al., 2020) . Table 2 presents these statistics.

In the next step of CCA, reliability at the construct level was evaluated through the commonly used Cronbach's alpha (α) and composite reliability (CR) statistics. These statistics' standard range is between 0.70 to 0.95. Table 2 was employed in this study. The AVE value above 0.50 is considered to explain more than 50% variance of the items constituting that construct. Table 2 enlists convergent validity statistics through the AVE metric.

The last step of CCA is to ensure the distinctiveness of the constructs. The latest guidelines have recommended the heterotraitmonotrait (HTMT) ratio of correlations. The standard values for HTMT should be below 0.90 (Hair et al., 2019) . 

Structural model assessment (SMA) was done by following the latest developments and guidelines on PLS-PM, which includes the performance of the following steps:

In the first step of SMA, multicollinearity's potential issue was assessed through variance inflation factor (VIF) statistic. The latest guidelines suggest that its values should be less than three (Hair et al., 2020) . Table 2 contained VIF values that are within the allowed limits.

The next step in SMA deals with the assessment of the direct and indirect hypothesized paths. The path coefficient (β) is one of the metrics for this purpose for which values were obtained through the bootstrapping procedure in the PLS algorithm. The guidelines for using and reporting SMA results suggested reporting percentile bootstrap confidence intervals (Hair et al., 2019) . The values of confidence intervals must not contain the zero value for the structural path's statistical significance. Table 4 presents these metrics' values, which shows that the direct and indirect hypotheses have been supported.

In SMA, the third step deals with the assessment of in-sample prediction wherein the coefficient of determination (R 2 ) and predictive relevance (Q 2 ) must be reported. The values of R 2 describe the percentage of variance in dependent variables(s) explained by the independent variable(s). Its values, 0.19, 0.33, and 0.67, are treated as small, moderate, and substantial, respectively (Chin, 1998) . Figure 2 shows that structural model results with R 2 values for psychological safety (0.290) and nurses' burnout (0.631) are moderate.

The predictive relevance (Q 2 ) was employed to know the predictive accuracy of a structural model. 

This study aimed to explore how servant leadership reduces nurses' burnout via the mediating mechanism of psychological safety. The findings lent credence to the direct effect of servant leadership on nurses' burnout and are consistent with the available handful of empirical studies on employee well-being. According to COR (Hobfoll, 2018) , First, it could mean that servant leaders provide the necessary job resources to buffer the adverse effects of high job demands that would typically cause burnout (Bakker et al., 2008) . It could also mean that servant leaders provide the needed job resources to help employees recover from burnout. In other words, employees working under servant leaders might be less prone to burnout because they will receive the necessary job resources either to cope with high job demands or to recover from burnout. We operationalized nurses' burnout as having feelings of emotional exhaustion, cynicism, and personal inefficacy. The characteristics of the servant leadership model advanced by Liden et al. (2008) are highly relevant to the dimensions of burnout. Empowerment, emotional healing, and ethical behaviour reduce employees' feelings of emotionally about emotional exhaustion.

The psychological safety is supported by our findings as a mediator between the relationship of servant leadership and burnout. A psychologically safe working environment nurtured by servant leadership is one of the critical preconditions for reducing nurses' burnout.

Precisely, psychological safety embodies employees' perceptions about their working environment instead of a specific task. When perceived safe, lower the risks of failure, rejection, and stress ultimately reduce burnout. Only one study has previously examined servant leadership's influence on employees' psychological safety (Chughtai, 2016) . Therefore, this study adds a much-needed contribution to the literature on servant leadership and burnout.

Our findings offered several implications for nursing management.

It offers a roadmap of how servant leadership reduces the potential burnout of nurses. In the face of epidemics, natural disasters and emergencies, the nursing leadership must ensure mental well-being and psychological safety of the workforce for two main reasons. One, to avoid employee turnover and retain the existing workforce by reducing burnout from demanding job requirements; two, to avoid adverse events and outcomes at the hospitals during patient care.

There is need to train leaders in servant leadership behaviour to develop empathy so that they can monitor employees' mental wellbeing by reducing emotional exhaustion through their support. When leaders are rude with their subordinates at the workplace may feel insecure and face psychological pressure, which leads to job burnout.

This attitude from subordinates in an organization may prompt them to doubt their professional efficacy in handling the pressure. Even worse, subordinates could become cynical and deliberately harm the organization as they are not concerned about their jobs. Leaders must be proactive in their relationship with subordinates, and they must lead them with empathy to have a cordial relationship within the organization (Salvarani et al., 2019) .

With a higher level of interpersonal acceptance accompanied by the element of empathy, servant leaders become able to cognitively adopt the psychological perspectives of others and experience feelings of warmth, compassion, and forgiveness when confronted with offenses, arguments, and mistakes. Head nurses with servant leadership approach build a close relationship with the nurses, listen to their opinions, involve them in decision making, encourage them to take risks for the betterment, and thus play a key role in cherishing employees' feelings of psychological safety.

According to Liden et al. (2008) , servant leaders give liberty and provide emotional strength to their subordinates to recognize their full potential. The fulfilment of hospitals' job requirements, especially during emergency services, needs more emotional healing due to work-related pressure. This study reconfirms the notion that head nurses with servant leadership style improves subordinates' job behaviour, which leads them to perform better. 

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The authors acknowledge help of Dr. Muhammad Saood Akhtar for helping us revise this manuscript.

Research Foundation (grant number 2020IVA079), Wuhan University of Technology, Wuhan, Hubei, China.