How to moderate emotional exhaustion among public healthcare professionals?

Abstract

This paper analyzes the mediating role of employees’ emotional exhaustion between laissez-faire leadership and employees’ job attitudes (intrinsic satisfaction and turnover intention), and also the moderating role of influence at work, interactional justice and helping behaviors on employees’ feelings of emotional exhaustion. Structural equation modeling and multigroup analysis were used in a sample of 511 public healthcare professionals. The results show that emotional exhaustion partially mediates the relationships between laissez-faire leadership and both intrinsic satisfaction and turnover intention. Influence at work moderates the relationship between laissez-faire leadership and emotional exhaustion; interactional justice moderates the relationship between emotional exhaustion and intrinsic satisfaction; and extra-role behaviors moderate the relationship between emotional exhaustion and turnover intention. To date, there are few studies analyzing the mediating role of emotional exhaustion in public healthcare, and there are no studies analyzing how its negative effects can be moderated. The conclusions may help human resources managers design new strategies to prevent and mitigate emotional exhaustion and contribute healthcare employees to cope with its serious effects, encouraging a healthy environment that gives priority to workers’ well-being and service quality.

1

Introduction

Emotional exhaustion, the core dimension of burnout, is identified with fatigue, irritability, frustration and feeling overextended, and depletes the resources of the employee (Maslach & Jackson, 1981). Emotional exhaustion has been previously studied in service organizations that work in direct contact with users, such as those of healthcare service. Healthcare professionals work in unhealthy environments, which may lead them to feel emotional exhaustion. Public healthcare workers have to deal with scarce economic and human resources, lack of management support (Gilbert, Laschinger, & Leiter, 2010; Maslach & Leiter, 2016), and a rigid organizational environment that cannot easily adapt to change (Mintzberg, 1979). According to job demands-resources theory (Demerouti, Nachreiner, Bakker, & Schaufeli, 2001), high job demands may make public healthcare professionals feel physically and emotionally depleted leading them to a state of emotional exhaustion. A ‘destructive’ style of leadership such as laissez-faire, which avoids decision-making or does not get involved in the performance of activities (Fors Brandebo, Nilsson, & Larsson, 2016; Fors Brandebo, Österberg, & Berglund, 2019), may lead to negative experiences among healthcare professionals and subsequent emotional exhaustion.

Conservation of resources theory (Hobfoll & Freedy, 1993) suggests that emotionally exhausted employees do not have sufficient energy to do their work properly, which may result in lower levels of intrinsic job satisfaction or greater turnover intention (Laschinger, Wong, & Grau, 2012; Suñer-Soler et al., 2014). Emotionally exhausted employees are unable to develop feelings of professional self-fulfillment, which undoubtedly has a negative effect on their intrinsic satisfaction (Tarcan, Hikmet, Schooley, Top, & Tarcan, 2017). Even though public healthcare workers generally have guaranteed job stability (Wright & Pandey, 2010), the development of emotional exhaustion may lead them to express turnover intention (Yanchus, Periard, & Osatuke, 2017), which may negatively affect the quality of the care they provide (De Simone, Planta, & Cicotto, 2018). According to job demands-resources theory and conservation of resources theory, emotional exhaustion may act as a mediator between certain employees’ job demands such as laissez-faire leadership and certain employees’ job attitudes such as job satisfaction and turnover intention. However, little research has been done on analysis of the mediating role of emotional exhaustion, and even less research has considered variables such as laissez-faire leadership, intrinsic job satisfaction or turnover intention among public healthcare professionals.

Job demand-resources theory suggests that the moderating capacity of several job resources on the relationship between job demands and employees’ emotional exhaustion depends on the characteristics of the job context and the combination of job demands and resources (Bakker & Demerouti, 2007). In public healthcare context, influence at work which refers to degree of control that employees have over their job activities may act as a moderator on the relationship between laissez-faire leadership and emotional exhaustion (Noblet, Page, & LaMontagne, 2013), helping to improve healthcare workers’ performance of tasks and mitigate the development of feelings of emotional exhaustion. Similarly, according to the theory of conservation of resources, organizational justice and specifically interactional justice, which refers to the quality of the interpersonal treatment among employees; and employees’ extra-role behaviors and specifically helping behaviors, which refers to interpersonal, cooperative, and affiliative behaviors among employees, may help minimize the effects of emotional exhaustion in public healthcare professionals, boosting their intrinsic job satisfaction and reducing their turnover intention, respectively. So, the perception of fair and respectful treatment, the use of good communication practices, and the establishment of informal support structures among colleagues may be useful strategies for mitigating the negative effects of emotional exhaustion.

This study is intended to deepen the study of the implications of public healthcare professionals’ emotional exhaustion. Professionals belonging to the medical and nurses’ staff have been considered because, although from different work specifications, they have in common that their work is directly aimed at improving the health of patients. To date, there has been very little research analyzing the mediating and moderating relationships around emotional exhaustion (López-Cabarcos, López-Carballeira, & Ferro-Soto, 2019). The lack of studies on this subject carried out in this specific study context, along with their inconclusive results justifies a study of these characteristics. For this reason, based on a sample made up of Spanish public healthcare employees, this paper aims to answer two fundamental questions. First, if emotional exhaustion mediates the relationship between laissez-faire leadership and employees’ job attitudes such as intrinsic job satisfaction and turnover intention; and second, if certain job resources such as influence at work moderates the relationship between laissez-faire leadership and employees’ emotional exhaustion; and, once employees are emotionally exhausted, if organizational variables such as interactional justice or helping behaviors may moderate the negative effects on employees’ intrinsic job satisfaction or turnover intention. So, the study aims to shed light on the prevalence of emotional exhaustion among public healthcare workers, and the need for strategies to prevent and mitigate it as a way to improve employees’ working conditions and quality of life as well as organizational functioning and service quality.

The structure of the paper is as follows: The first section offers the conceptual framework of the paper including the study hypotheses. The second section sets out the methodology used. The third section shows the main results and findings obtained. The fourth section includes the discussion of the study results. And finally, the fifth section highlights the main conclusions and includes future lines of research.

2

Literature review

Burnout arises as a reaction to prolonged exposure to both emotional and interpersonal stressors in the working environment (Maslach & Jackson, 1981). The key component of burnout is emotional exhaustion (Peng, Chen, Chang, & Zhuang, 2016), which refers to feelings of fatigue and of being overextended, irritability, frustration, and depletes the resources of the employee (Maslach & Jackson, 1986). Emotional exhaustion is the key, and most stable component of burnout (Schaufeli & Enzmann, 1998), and the first stage of the burnout process and therefore the essential element for intervention programs (Maslach, 2003).

The special nature of healthcare work makes this environment especially complex. The necessary quality required for patient care together with the fact that each patient must be considered as ‘unique’ constitute the main restrictions for healthcare professionals (Khatri, Gupta, & Varma, 2017), which could lead them to suffer emotional exhaustion. Healthcare workers have to do their work with maximum accuracy and responsibility, have to care for a large number of patients in a short time, and may have to face emergency situations in intense working days (Boudrias, Trepanier, Foucreault, Peterson, & Fernet, 2020). Moreover, the distribution of work shifts may lead to sleep disorders, and direct contact with disease and death may lead to a feeling of failure and other negative situations (Kilroy, Flood, Bosak, & Chênevert, 2017). In parallel, the actual organizational context may also foster the appearance of emotional exhaustion among healthcare workers because of political restrictions, limited funding, staff shortages and lack of management support (Gilbert et al., 2010; Maslach & Leiter, 2016).

Public healthcare system, which is characterized by rigid and bureaucratic organizational structures and is based on specialization, professional hierarchy, authority, rule orientation, and inflexibility (Wynen & Kleizen, 2019) is very difficult to change (Mintzberg, 1979) and does not promote employee well-being. Its public nature demands to provide a high-quality service and not necessarily to achieve financial returns (Garde Sánchez, Rodríguez Bolívar, & López Hernández, 2017; Marino & Quattrone, 2019). Such environment may lead to a loss of energy and motivation among healthcare professionals and may give rise to situations that damage their health to the extent that they will be unable to fulfill their job requirements (Maslach & Leiter, 2016) and will find it difficult to achieve professional success (Dhaini et al., 2018), reducing the time available for quality care of patients (Aiken et al., 2012).

2.1

The relationship between laissez-faire leadership and emotional exhaustion

Job demands-resources theory states that high job demands, such as poorly-designed work posts or excessive job performance requirements, may lead to the loss of both physical and mental energy in employees and ultimately to emotional exhaustion. Previous research has confirmed strong relationships between several job demands an emotional exhaustion in several fields such as healthcare (Dhaini et al., 2018; Portoghese et al., 2017; Van Bogaert et al., 2017). At this point, it should be of interest to analyze the relationship between leadership style and employees’ emotional exhaustion.

Leaders are people who from their higher positions can have a significant influence on the behavior of individuals (Skakon, Nielsen, Borg, & Guzman, 2010; Stordeur, D'hoore, & Vandenberghe, 2001). In this sense, leaders should encourage employees to reach shared goals and provide the necessary tools and skills to successfully complete work tasks (Courtright, Colbert, & Choi, 2014). Constructive leadership, based on support, participation, resource optimization, motivation or subordinates’ job satisfaction (Aasland, Skogstad, Notelaers, Nielsen, & Einarsen, 2010; Einarsen, Aasland, & Skogstad, 2007), may have positive effects on job satisfaction, well-being and work performance (Schyns & Schilling, 2013). In environments of uncertainty and urgency such as healthcare, constructive leadership encourages healthcare professionals to actively participate in decision-making and task management (Rahmani, Roels, & Karmarkar, 2018), helps improve organizational processes and the quality of patient care (Mah’d Alloubani, Almatari, & Almukhtar, 2014), and prevents emotional exhaustion (Stordeur, D’hoore, & Vandenberghe, 2001). Conversely, destructive leadership, which shows systematic, repeated behaviors that go against the legitimate interests of the organization, either hindering the achievement of goals or abusing subordinates in one any way or another (Einarsen et al., 2007), may have very negative effects both on the organization and employees. Destructive leadership may also arise in passive behaviors, such as laissez-faire leadership (Fors Brandebo et al., 2016, 2019; Kelloway, Sivanathan, Francis, & Barling, 2005; Skogstad, Einarsen, Torsheim, Aasland, & Hetland, 2007).

Laissez-faire leadership is identified with a lack of leadership in decision-making processes and in the performance of the organization’s functions (Avolio & Bass, 2004; Bass, 1985). A laissez-faire leader delegates the decisions to others (Zareen, Razzaq, & Mujtaba, 2015) or delays their adoption, causing negative effects on participation, feedback and compensation (Zwingmann, Wolf, & Richter, 2016). Moreover, such leaders do not interact with subordinates, find it difficult to design measures to motive them or boost their job satisfaction, and do not take responsibilities (Avolio & Bass, 2004). Previous research states that laissez-faire leadership may lead to negative attitudes among subordinates, such as lower job satisfaction (Skogstad et al., 2014), higher turnover intention (Schyns & Schilling, 2013), higher stress levels (Erickson, Shaw, & Agabe, 2007), or the appearance of feelings of emotional exhaustion (Breevaart, Bakker, Hetland, & Hetland, 2014; Hetland, Sandal, & Johnsen, 2007). Despite its potential negative consequences (e.g. incompetence, lack of knowledge, violate subordinates’ expectations), laissez-faire leadership is very present in public healthcare. The reason is that public healthcare professionals must carry out very complex tasks with certain urgency within highly bureaucratic, formal and centralized organizational structures (Mintzberg, 1979; Wright & Pandey, 2010). This situation can lead public administrators and policymakers to try to avoid responsibilities delegating some important decisions, at the same time that healthcare professionals must carry out tasks that involve a high degree of improvisation requiring very fast responses. All this justifies laissez-faire leadership as the leadership style more common in public healthcare although not necessarily the best. Little research has analyzed the relationship between laissez-faire leadership and emotional exhaustion in healthcare organizations, and the results are mixed. While Stordeur et al. (2001) suggest that passive management-by-exception is not significantly related to emotional exhaustion, other authors confirm that laissez-faire leadership can function as an exposing factor for emotional exhaustion (Kanste, Kyngas, & Nikkila, 2007).

2.2

The relationship between emotional exhaustion and the employees’ job satisfaction and turnover intention

According to conservation of resources theory, emotionally exhausted employees are unable to carry out their activities correctly, so they become more selective and sensitive when using new resources. This situation may lead them to feel less satisfied at work (Laschinger et al., 2012) or to express turnover intention (Suñer-Soler et al., 2014). Both job satisfaction and turnover intention have serious implications because they may increase medical errors, result in longer patient recovery times or reduce health service quality (Piko, 2006; Tarcan, et., 2017).

Job satisfaction is a positive, pleasurable emotional status that results from a subjective perception of the subject’s work experiences (Locke, 1969; Salas-Vallina, Alegre, & Fernandez Guerrero, 2018). Specifically, intrinsic satisfaction is related to the degree of affectivity of employees with regard to the characteristics of the job (De Witte, Vander Elst, & de Cuyper, 2015). In public healthcare, it is associated with the need to feel self-fulfillment to work (Decker, Harris-Kojetin, & Bercovitz, 2009) and is quite difficult to achieve. Aspects such as low levels of responsibility, poor prospects for promotion, little variety in tasks or little freedom to choose the most appropriate working method may lead to lower levels of intrinsic satisfaction among healthcare professionals. Lower levels of intrinsic satisfaction may be due, among other reasons, to higher job demands or the development of feelings of emotional exhaustion and less self-fulfillment (Tarcan, et al., 2017). Emotionally exhausted workers cannot perform their job tasks properly and they feel less satisfied with their works, even though minimum working conditions are guaranteed. The little previous research on the relationship between emotional exhaustion and intrinsic job satisfaction in public healthcare concludes that it is significant and negative (Tarcan, Tarcan, & Top, 2016; Tarcan, et al., 2017).

Turnover intention is a cognitive process in which an employee thinks about and wishes to leave the job (Mobley, Horner, & Hollingsworth, 1978). Jobs in the public sector are characterized by job stability (Wright & Pandey, 2010; Zeffane & Melhem, 2017), so that in practice it is unlikely that the worker will actually leave the organization. However, the very desire to leave has a negative effect on the work of healthcare professionals, causing interruptions in the service, reducing the quality of the service provided to patients or their families, or increasing the probability of making medical errors (De Simone et al., 2018; O’Brien-Pallas et al., 2006). As already stated, emotionally exhausted healthcare professionals do not have sufficient energy to correctly carry out their activities at work, so they may feel a wish to leave the organization as a way of facing this loss of energy (Hobfoll & Freedy, 1993). Previous research has concluded that emotional exhaustion is significantly and positively related to turnover intention among healthcare professionals (Knudsen, Ducharme, & Roman, 2009; Yanchus et al., 2017). Therefore, laissez-faire leadership may lead to emotionally exhausting employees, who in turn may show lower levels of intrinsic satisfaction and a greater turnover intention. To date, no study has analyzed the mediating role of emotional exhaustion between laissez-faire leadership and intrinsic job satisfaction or turnover intention. Therefore, the following hypotheses are proposed: H1- Emotional exhaustion mediates the relationship between laissez-faire leadership and intrinsic job satisfaction; H2- Emotional exhaustion mediates the relationship between laissez-faire leadership and turnover intention.

2.3

The moderating role of influence at work

The job demands-resources theory also suggests that certain job resources may act as ‘buffers’ for the effect of high job demands on emotional exhaustion, promoting a process of motivation that helps workers to achieve their goals at work and encourages employee growth and development (Bakker & Demerouti, 2007). According to Xanthopoulou et al. (2007), provide job resources to public healthcare professionals may act as an inhibitor of feelings of emotional exhaustion and may be a source of motivation to improve service quality.

Influence at work can be defined as the degree of control that employees have over their job activities, such as the method used, the order followed or the tasks to be done (Fernet, Guay, & Senecal, 2004; Kowalski et al., 2010; Moncada, Llorens, Navarro, & Kristensen, 2005). In public health, influence at work can be considered both as a job resource and a job demand. As a job resource, it means that the decision-making autonomy can help employees to gain other resources that facilitate to complete their tasks properly (Kowalski et al., 2010), reducing their emotional exhaustion. As a job demand, it means that the indiscriminate delegation of tasks and consequent decentralization of decision-making (sometimes motivated by passive leadership styles) may lead to the employees’ emotional exhaustion because of the number of important decisions that have to be taken in short spaces of time (Knudsen et al., 2009). Public healthcare, with its high degree of centralization and formalization, does not promote freedom in decision-making for healthcare professionals. However, a high degree of autonomy and freedom of action can guarantee immediate, precise and correct responses, affecting the quality of the service offered (Galletta, Portoghese, & Battistelli, 2011). It can also affect the well-being, motivation and satisfaction of healthcare professionals by activating positive, autonomous behaviors at work (Noblet et al., 2013). Therefore, the provision of decision-making autonomy based on workers’ experience and knowledge (Laschinger, 2004) can help mitigate the development of feelings of emotional exhaustion. Little research has analyzed the moderating role of influence at work on emotional exhaustion and shows mixed results (Loh, Idris, Dollard, & Isahak, 2018; Xanthopoulou et al., 2007). To date, no research has analyzed the moderating role of influence at work in the relationship between laissez-faire leadership and emotional exhaustion. Therefore, the following hypothesis is proposed: H3- Influence at work moderates the relationship between laissez-faire leadership and employees’ emotional exhaustion.

2.4

The moderating role of interactional justice and helping behaviors

Conservation of resources theory also suggests that by means of motivational processes, the presence of certain resources at work can help interrupt the loss cycle in which emotionally exhausted employees find themselves. Public administrations are obliged to guarantee fairness in their functioning (Wright & Pandey, 2010), so the perception of unfairness may threaten their productivity (Laschinger, 2004), and lead employees to show lower levels of satisfaction and greater turnover intention (Colquitt, 2001). Public activity justifies that of all types of justice, interactional justice is the most relevant, especially when employees experience negative or unfavorable situations (such as the development of feelings of emotional exhaustion). Interactional justice relates to impartiality and how employees are treated in an organization (Bies & Moag, 1986; Colquitt, 2001). It refers to sensitive, respectful and honest treatment, and relates to the human part of the organizational system (Cohen-Charash & Spector, 2001). Perception of fair, equal and respectful treatment among employees can help them to feel better, to have more efficient working teams, to generate greater and better communication, or to improve the quality of treatment given to patients and their families (Mohamed, 2014). Employees’ perception of interactional justice can also lead them to improve their intrinsic job satisfaction and/or to decrease their wish to leave the organization. To date, there have been no previous studies examining the moderating role of interactional justice in the relationship between emotional exhaustion and intrinsic job satisfaction or turnover intention. Therefore, the following hypotheses are proposed: H4- Interactional justice moderates the relationship between emotional exhaustion and intrinsic satisfaction; H5- Interactional justice moderates the relationship between emotional exhaustion and turnover intention.

As already stated, public healthcare professionals have to perform their tasks in environments that are complex because of factors such as the distribution of work shifts, caring for a large number of patients in short spaces of time, intense working days, shortage of staff or the requirement to draw up effective treatments and diagnoses (Bakker, Demerouti, & Euwema, 2005; Gilbert et al., 2010; Tziner, Rabenu, Radomski, & Belkin, 2015). The shaping of informal organizational structures can promote voluntary cooperative behaviors to facilitate the work of healthcare professionals (Xerri & Brunetto, 2013). Organizational citizenship behaviors (OCBs) are discretionary behaviors that do not receive direct compensation from the organization (Organ, 1988) and are not subject to standards or formal expectations (Farh, Earley, & Lin, 1997). One type of OCBs are helping behaviors characterized by being interpersonal, cooperative, and affiliative extra-role behaviors (Liang, Shih, & Chiang, 2015), that express the help given voluntarily to colleagues and to new arrivals (Podsakoff, MacKenzie, Paine, & Bachrach, 2000) with the intention of solving problems arising in the performance of tasks (Paille, 2013). This type of spontaneous behaviors, focused on caring, sharing or cooperating (Guerrero & Challiol-Jeanblanc, 2016), can help limit the bureaucracy and excessively rigid procedures that characterize public healthcare. At the same time, providing and receiving help from colleagues may help improve the cohesion of the group, develop a feeling of belonging to it, and act as an element of motivation (Paille, 2013). In healthcare context helping behaviors may improve the quality of the service provided, increase patient satisfaction and productivity, and act as a factor of attraction and retention of the best professionals (Othman, 2006; Podsakoff et al., 2000). It is therefore reasonable to assume that helping behaviors can act as buffers for emotional exhaustion in employees, who will thus have greater intrinsic job satisfaction and/or fewer desires to leave the organization. To date, there are no previous studies examining the moderating role of helping behaviors in the relationship between emotional exhaustion and intrinsic job satisfaction or turnover intention. Therefore, the following hypotheses are proposed: H6- Helping behaviors moderate the relationship between emotional exhaustion and intrinsic job satisfaction; H7 - Helping behaviors moderate the relationship between emotional exhaustion and turnover intention.

Fig. 1 shows the study proposed model.

Fig. 1.

Proposed model.

3

Methodology

3.1

Participants and procedure

The study was carried out among a random sample of 800 medical and nurses staff belonging to public Spanish healthcare system. A questionnaire in paper form with brief instructions and a statement of confidentiality regarding data processing was sent between April and June 2018 to the study sample, yielding 511 useable questionnaires (response rate: 63.87%). 30.52% of respondents were men (N = 156), average age 49.25 (SD=8.616), and 69.47% were women (N = 355), average age 46.13 (SD=9.180). 79.1% were in open-ended employment and 20.9% in temporary employment (N = 404 and N = 107, respectively).

Structural equation modelling (SEM) and multigroup analysis with the SPSS 22.0 AMOS package were used to analyze the data and the hypotheses proposed. SEM is a technique that aims to establish linear structural relations usually formulated by linear regression equations graphically expressed by so-called path diagrams (Bentler, 1988). Specifically, the choice of SEM responds to the fact that it is a flexible methodology that allows dealing not only with simple or multiple linear regressions, but with a system of regression equations, which makes it an optimal technique when several equations must be analyzed simultaneously (Byrne, 2009).

3.2

Instruments

The emotional exhaustion (EE) scale proposed by Maslach and Jackson (1986) was used, with nine items based on a 7-point Likert scale (1 meaning never and 7 daily). It included items such as “I feel emotionally drained by my work”. The scale for laissez-faire leadership (LF) was proposed by Bass and Avolio (1995), with four items based on a 5-point Likert scale (1 meaning never and 5 always). It included items such as “Leader avoids making decisions”. Intrinsic satisfaction (IS) was measured using the scale developed by Warr, Cook, and Wall (1979)), with seven items based on a 7-point Likert scale (1 meaning extremely dissatisfied and 7 extremely satisfied). It included items such as “The recognition you get for good work”. Turnover intention (TI) was measured using an adapted version of the scale proposed by Mobley et al. (1978), with five items based on a 5-point Likert scale (1 meaning strongly disagree and 5 strongly agree). It included items such as “I often think of leaving this health service”. The scale for influence at work (IW) was proposed by Kristensen, Hannerz, Høgh, and Borg (2005)), with four items based on a 5-point Likert scale (1 meaning never and 5 meaning always). It included items such as “Do you have a large degree of influence concerning your work?”. The scale for interactional justice (IJ) was drawn up by Greenberg (1993), with four items based on a 5-point Likert scale 1 meaning totally disagree and 5 meaning totally agree). It included items such as “My immediate superior is very sincere with me”. Finally, the scale for helping behavior (HB) was proposed by Coyle-Shapiro (2002), with five items based on a 5-point Likert scale (1 meaning not at all and 5 to a very great extent). It included items such as “Helps others who have heavy workloads”.

4

Results

4.1

Common method bias

To avoid potential common method variance, the recommendations by Podsakoff, MacKenzie, Lee, and Podsakoff (2003)) were followed. Harman (1967) single factor test (1967) was performed and revealed seven factors (eigenvalues >1), which explained 61.55% of the total variance. No single factor responsible for most of the variance emerged (Christmann, 2000). In addition, all the variables were loaded onto a single factor resulting in a poor fit significantly worse than that of the measurement model (Korsgaard & Roberson, 1995). Most of the data variance was therefore explained by individual constructs, so common method variance bias was apparently not a significant problem in this study.

4.2

Model analysis

Simple correlations, Cronbach’s alpha, descriptive statistics, average variance extracted (>0.5) and composite reliability (>0.7) (Fornell & Larcker, 1981) are presented in Table 1. As expected, all variables correlated positively with each other.

Table 1.

Means, standard deviations, correlations and estimated reliabilities.

	M	SD	LF	EE	IS	TI	IW	IJ	HB
LF	2.2794	.95171	(.881)
EE	3.4577	1.07865	.153**	(.827)
IS	4.1236	1.18382	−.428**	−.472**	(.862)
TI	1.6849	.92749	.191**	.317**	−.239**	(.832)
IW	2.8141	.90555	−.213**	−.151**	.452**	−.030	(.771)
IJ	3.3659	.98413	−.576**	−.245**	.522**	−.201**	.253**	(.916)
HB	4.1942	.53831	-.064	-.074	.032	-.067	−.154**	.129**	(.751)

* p<.05, ** p<.01.

Note: N = 511, LF = Laissez-faire leadership; EE = Emotional exhaustion; IS = Intrinsic satisfaction; TI = Turnover intention; IW = Influence at work; IJ = Interactional justice; HB=Helping behavior. Cronbach’s α on the diagonal.

The scale’s reliability was supported by confirming its convergent and discriminant validity (Hair, Black, Babin, & Anderson, 2010). Goodness-of-fit indices of the measurement model were good: χ²(df) = 428.499(180), p < .001, χ²/df = 2.381, NFI = .915, TLI = .940, CFI = .949; RMSEA = .052, GFI = .924; AGFI = .902. Goodness-of-fit indices for the structural model also presented good values: χ²(df) = 428.599(181), p < .001, χ²/df = 2.368, NFI = .915, TLI = .941, CFI = .949; RMSEA = .052, GFI = .924; AGFI = .902. The structural paths were significant between laissez-faire and emotional exhaustion (β = .182; p < .001), emotional exhaustion and intrinsic satisfaction (β=-.465; p < .001), emotional exhaustion and turnover intention (β = .336; p < .001), laissez-faire and intrinsic satisfaction (β=-.395; p < .001), and laissez-faire and turnover intention (β = .150; p < .001). The results showed that laissez-faire accounts for 3.6% of healthcare professionals’ emotional exhaustion, which in turn accounts for 44.3% of their intrinsic satisfaction and 15.8% of their turnover intention.

From the results, it was concluded that emotional exhaustion partially mediates the relationships between laissez-fare and intrinsic satisfaction, and between laissez-fare and turnover intention. To fully confirm the partial mediating role of emotional exhaustion in both relationships, two additional models were tested in each case (Baron & Kenny, 1986). Table 2a and 2b shows the model-fit statistics and the path coefficients of the three models, confirming partial mediations in both cases. The mediating effect of emotional exhaustion in the relationship between laissez-fare and intrinsic satisfaction (z=-3.94, p < .001) and laissez-fare and turnover intention (z=-3.38, p < .001) was also supported by the Sobel (1982) test. Table 2a shows that the chi-square of Model 3 (partial mediation) is lower than the chi-square of Model 2 (direct effects) and significantly different (Δ χ² = 135.235, Δdf = 2); it is also lower than the chi-square of Model 1 (full mediation) and significantly different (Δ χ² = 77.146, Δdf = 1). Table 2b also shows that the chi-square of Model 3 (partial mediation) is lower than the chi-square of Model 2 (direct effects) and significantly different (Δ χ² = 60.033, Δdf = 2); it is also lower than the chi-square of Model 1 (full mediation) and significantly different (Δ χ² = 10.605, Δdf = 1). In addition, variance accounted-for (VAF) fell within the range of 0.20 to 0.80 (Hair, Sarstedt, Hopkins, & Kuppelwieser, 2014) in both cases, supporting the partial mediation of emotional exhaustion. The above results established that Model 3 (partial mediation) was the best choice in both cases, supporting H1 with emotional exhaustion mediating the relationship between laissez-faire leadership and intrinsic job satisfaction; and H2 with emotional exhaustion mediating the relationship between laissez-faire leadership and turnover intention.

Table 2.

Fit results and path coefficients for structural equation models.

Table 2a Emotional exhaustion mediating between laissez-faire leadership and intrinsic satisfaction
	χ^2(df)	GFI	RMSEA	AGFI	NFI	TLI	CFI	χ^2/df
Model 1	394.257(130)	.92	.063	.895	.906	.923	.935	3.03
Model 2	452.219(131)	.914	.069	.887	.893	.908	.921	3.45
Model 3	317.111(129)	.936	.053	.913	.925	.945	.954	2.46

Standardized coefficients and (t-values)
	Model 1	Model 2	Model 3
LF-IS		−.468(-10.40)***	−.382(-8.68)***
LF-EE	.213(4.09)***		.181(3.55)***
EE-IS	-.56(-14.36)***		−.48(-11.43)***

Table 2b Emotional exhaustion mediating between laissez-faire leadership and turnover intention
	χ^2(df)	GFI	RMSEA	AGFI	NFI	TLI	CFI	χ^2/df
Model 1	206.596(73)	.944	.06	.919	.937	.948	.958	2.83
Model 2	256.024(74)	.935	.069	.908	.922	.93	.943	3.46
Model 3	195.991(72)	.948	.058	.924	.940	.951	.961	2.72

Standardized coefficients and (t-values)
	Model 1	Model 2	Model 3
LF-TI		.209(4.02)***	.150(3.06)**
LF-EE	.188(3.69)***		.180(3.53)***
EE-TI	.365(8.49)***		.334(7.77)***

Note: Model 1: Total mediation; Model 2: Direct effect; Model 3: Partial mediation.

* p<.05, ** p< .01, *** p< .001.

4.3

Moderation

This paper analyzes the moderating effect of influence at work in the relationship between laissez-faire and emotional exhaustion, and the moderating effects of interactional justice and helping behavior in the relationships between emotional exhaustion and intrinsic satisfaction, and emotional exhaustion and turnover intention. Multigroup analyses were used to test all the moderation effects. First, factor loading invariance among the groups was conducted by testing the significance of the chi-square differences between two CFA models, one in which the factor loadings were constrained so that they were the same in both groups, and the other without constraints. Regarding the moderating role of IW, Table 3a shows that the chi-square difference was significant (Δχ² = 248.437, Δdf = 9, p < .001), suggesting there was no factor loading invariance. Series of multiple group analyses were performed to analyze path differences. The result was that influence at work showed a factor loading variant in the relationship between laissez-faire and emotional exhaustion, supporting H3 with influence at work moderating the relationship between laissez-faire leadership and employees’ emotional exhaustion.

Table 3a.

Moderation effects of influence at work.

	χ^2(df)	χ2/df	Δχ²(Δdf)	CFI	RMSEA	p-value	Invariant
Multiple Group CFA
Baseline (no constraints)	637.348(362)	1.76		.941	.039
Factor loading invariance	885.785(371)	2.39	248.437(9)	.890	.052	.000	No
Multiple Group SEM Model								Moderation
Path invariance	640.058
Const LF→EE	640.334(363)					<.1	No	Yes

The moderating role of interactional justice was performed in the same way and the results showed that interactional justice moderates the relationship between emotional exhaustion and turnover intention. Table 3b shows a significant difference in the chi-square (Δχ² = 249.153, Δdf = 9, p < .001), and suggests there is no factor loading invariance, supporting H5 with interactional justice moderating the relationship between emotional exhaustion and turnover intention. However, the moderating role of interactional justice in the relationship between emotional exhaustion and intrinsic satisfaction was not supported, rejecting H4.

Table 3b.

Moderation effects of interactional justice.

	χ2(df)	χ2/df	Δχ²(Δdf)	CFI	RMSEA	p-value	Invariant
Multiple group CFA
Baseline (no constraints)	669.920(362)	1.85		.933	.041
Factor loading invariance	919.073(371)	2.48	249.153(9)	.881	.054	.000	No
Multiple Group SEM Models								Moderation
Path invariance	672.630
Const EE→IS	670.057(363)					n.s.	Yes	No
Const EE→TI	672.732(363)					<.1	No	Yes

Finally, Table 3c shows that helping behavior moderates the relationship between emotional exhaustion and intrinsic satisfaction. The chi-square difference is significant (Δχ² = 286.644, Δdf = 9, p < .001), and does not suggest factor loading invariance, supporting H6 with helping behaviors moderating the relationship between emotional exhaustion and intrinsic job satisfaction. However, the moderating role of helping behavior in the relationship between emotional exhaustion and turnover intention was not supported, rejecting H7. All the above-mentioned results are shown in Fig. 2.

Table 3c.

Moderation effects of helping behaviors.

	χ2(df)	χ2/df	Δχ²(Δdf)	CFI	RMSEA	p-value	Invariant
Multiple group CFA
Baseline (no constraints)	627.352362)	1.73		.946	.038
Factor loading invariance	913.996(371)	2.46	286.644(9)	.889	.054	.000	No
Multiple Group SEM Models
Path invariance	633.83							Moderation
Const EE→IS	637.834(363)					<.01	No	Yes
Const EE→TI	629.930(363)					n.s.	Yes	No

p<.1* (.90 confidence), p<.05** (.95 confidence), p<.01*** (.99 confidence).

Fig. 2.

Structural model.

5

Discussion and managerial implications

This research attempts to analyze the role of emotional exhaustion in public healthcare, and the capacity of certain variables to moderate it. In line with previous research supporting the partial mediating role of emotional exhaustion (Alola, Olugbade, Avci, & Öztüren, 2019; Karatepe, 2011;), the results indicate that emotional exhaustion partially mediates the relationships between laissez-faire leadership and intrinsic satisfaction and between laissez-faire leadership and turnover intention. Thus, laissez-faire leaders may lead healthcare professionals to suffer emotional exhaustion, who in turn may develop feelings of dissatisfaction and a wish to leave the organization. A laissez-faire leadership style may lead employees to feel dissatisfied with aspects of healthcare activity, such as the level of responsibility held, the prospects for promotion, the variety of tasks to be performed or the autonomy to choose the most appropriate working method, all of which may cause failures or errors with irreparable consequences. In addition, a laissez-faire leadership style may also lead employees to wish to leave the organization. Although the characteristics and nature of the public sector guarantee job stability, the mere idea that employees wish to leave the organization may cause interruptions and errors in their job performance which may affect the quality of the service offered. The results show that, the direct relationship between laissez-faire leadership and intrinsic job satisfaction or turnover intention is as important as the relationship proposed using emotional exhaustion as the mediating variable. This means that not preventing emotional exhaustion has very negative effects on the job attitudes of healthcare professionals; and also that a laissez-faire leadership may negatively influence employees’ satisfaction, well-being and quality of life, and at the end the quality of the service provided.

Consequently, human resources managers of public healthcare should design strategies that aim to reduce and, more importantly, prevent the negative effects of emotional exhaustion mainly if crisis situations such as the COVID-19 pandemic occur. The objective should be to improve the working conditions and the quality of life for all employees, offering at the same time a higher quality healthcare service. In fact, uncertain and complex work environments such as the COVID-19 pandemic can be an exciting opportunity for encouraging public administrations and healthcare managers to think innovative formulas related to new ways of working and service delivery. Such strategies should include guidance on the leadership style to be used, which should be positive, inspirational, and constructive as an effective way to improve the employees’ well-being and the service quality. Proactive decision-making and actions such as participation and involvement in working activities, the establishing of mechanisms for motivation, and the design of transparent and credible communications policies should be carried out by public healthcare leaders to prevent employees from developing feelings of emotional exhaustion together with job dissatisfaction and turnover intention.

In line with previous research supporting the moderating role of influence at work (Bakker, Le Blanc, & Schaufeli, 2005; Willemse, De Jonge, Smit, Depla, & Pot, 2012), this study confirms that this job resource weakens the influence of laissez-faire leadership on employees’ emotional exhaustion. Thus, providing decision-making autonomy to healthcare professionals may help improve the management of the resources they need for the successful performance of their tasks, reducing at the same time the possibility of suffering emotional exhaustion. Moreover, job autonomy may act as a source of motivation for healthcare staff, who probably interpret that it grants them the ‘freedom’ gained from their knowledge and experience to take the best decisions at all times. Thus, setting targets and allocating tasks should be done in such a way that room is left for action and discretion in the performance of tasks.

The results also show that perception of interactional justice or carrying out extra-role behaviors may help mitigate emotional exhaustion and its influence on the employees’ intrinsic satisfaction or turnover intention. A perception of fair, equal and respectful treatment from superiors or colleagues reduces turnover intention in emotionally exhausted employees. This result is in line with prior studies that conclude that a perception of justice may provide compensatory resources to replenish depleted resources for coping with feelings of emotional exhaustion (Hur, Park, & Moon, 2014). Designing confident work environments based on clear, transparent and direct communication mechanisms and on respectful, honest human relations prevents the development of feelings of emotional exhaustion or moderates its negative effects such as turnover intention. In this sense, fostering social interaction between managers and healthcare professionals can have very positive effects such as strengthening teamwork, making effective medical decisions, and improving healthcare professionals’ well-being. Therefore, promoting less formalized structures through constructive leaderships, designing training activities aimed to carry out tasks with higher quality, or establishing permanent, transparent and fluid communication channels can lead to avoid healthcare professionals’ turnover intention. In parallel, the results also show that helping behaviors moderate the relationship between employees’ emotional exhaustion and their intrinsic satisfaction. The possibility of workers carrying out extra-role behaviors that go beyond their contractual obligations related to helping others within the organization, helps buffer the negative effects that emotional exhaustion exerts on their intrinsic job satisfaction. Previous research has pointed out that employees who suffer psychosocial risks may use extra-role behaviors to acquire some power during psychologically risky processes that may help them endure the situation (Verdasca, 2015). Creating and stimulating informal networks or spaces allowing healthcare professionals to cooperate with each other to resolve work problems, or proposing ways to avoid the emergence of complex situations may encourage positive attitudes and behaviors that may help minimize the negative effects of employees’ emotional exhaustion on their intrinsic satisfaction. Undoubtedly, these results are very interesting because they are coherent with the own nature of helping behaviors and interactional justice. The cooperative and collaborative behaviors act as a powerful moderator in the relationship between emotional exhaustion and employees’ intrinsic job satisfaction (not on employees’ turnover intention); while the existence of a fair, equal and respectful treatment among employees act as a powerful moderator in the relationship between emotional exhaustion and employees’ turnover intention (not on employees’ intrinsic job satisfaction). In other words, exhibiting behaviors that go beyond what is formally required can lead to increase the employees’ intrinsic job satisfaction. The reason may be that both variables are closely and directly related to the individual, who finally decides how they relate and with how much intensity. However, the responsibility for the perception by employees of fair and honest interpersonal relationships with transparent and reliable information flows lies with the organization, which in this way can directly influence their desire to leave it or not.

6

Conclusions and future research

In line with the corporate social responsibility approach, proper management of job resources and demands may lead to staff well-being. Therefore, ascertaining and understanding the causes behind feelings of emotional exhaustion may help public healthcare administrations to draw up programs and strategies to prevent its appearance or at least to reduce its negative effects. A constructive leadership style helps to improve employee well-being and, consequently, the quality of the service provided. In addition, ensuring that employees have tools and resources to buffer (and prevent) the effects of emotional exhaustion can help them cope with its serious effects. For this purpose, it is vital for positive, motivating and stimulating experiences to be developed in the working environment so that workspaces become healthy and give priority to workers’ well-being and service quality.

As any empirical study, this study has some limitations. Its cross-sectional survey design, which is based on the use of data collected from a single-sitting, self-reporting measure, could have led to a common method variance bias (Campbell & Fiske, 1959). As discussed earlier, several procedures were undertaken in order to minimize the effects and assess the scope of this problem, which is common to many social studies. Although only one country has been considered in the study sample which can make it difficult to generalize the results obtained, a deep analysis of the public healthcare services of the main European countries has shown significant similarities between them. Anyway, future studies should consider other countries or even other organizational contexts in both the public and private spheres to highlight their idiosyncrasies as well as to generalize the results of this research. Although the variables included in this study are very important, future research should consider other job demands (e.g. quantitative requirements), other job resources (e.g. social support) and other organizational variables (e.g. organizational commitment) to better understand the role of emotional exhaustion and its effects on other outcomes (e.g. job performance). It would also be of interest to analyze whether there are differences when considering the private healthcare system or even other types of healthcare professionals.