Effect of Mediation of Perceived Organizational Support in the Relationship between Role Stress and Emotional Exhaustion of Nurses

Abstract :

Nurses are highly susceptible to burnout which affects quality of patient care and their own well-being. Emotional Exhaustion is considered as a core dimension of burnout. It has been found that some sources and consequences of Nursing Role Stress (NRS) vary based on National Culture. In India Nurses do not enjoy high status in healthcare set-up as their counterparts in West. Studies in West and Far-East indicate Perceived Organizational Support (POS) mitigates Nurses’ Emotional Exhaustion. Study has been undertaken to analyze impact of POS on Emotional Exhaustion of nurses and also aimed at ascertaining whether Low Status of Nurses and operating in High-Power Distance environment in India serve as a cause of Stress.

506 Nurses of Six Private Hospitals of Kolkata participated. Data was analyzed using Correlations and Regression Analysis and Mediation Analysis was confirmed by Sobel Test. Study revealed POS Partially Mediates in the relationship between NRS and Emotional Exhaustion of Nurses. Low Status of Nurses serve as a Major Source of NRS. Discussion on the Result, Academic and Managerial Implications, Limitations, Scope of Research, Conclusion discussed in the Study. This Study may be useful for Healthcare Managers to design appropriate policy to control Emotional Exhaustion of Nurses.

Keywords :
Emotional Exhaustion; Nurse; Nursing Role Stress; Perceived Organizational Support; Power Distance Environment
1. Introduction

Job Burnout considering its impact on human health and performance is a subject of study for several decades and voluminous study has been made in different countries. Human service professions are considered as highly susceptive to burnout. Maslach and Leiter (2016) described these occupations as those where others' needs are put forward before doer than his/her need, work for longer hours and expected to do whatever possible for benefits of clients or service takers. Based on Schaufeli and Enzmann (1998), Maslach and Leiter (2016) stated that burnout is associated with different forms of negative reactions and withdrawal-like job dissatisfaction, low organizational commitments, absenteeism, intention to leave the job and turnover. Considering its adverse effects Burnout has become a serious issue in most western countries (Bakker & Demerouti, 2017).

Maslach and Leiter (2016) described Burnout as a psychological syndrome arising as a prolonged response to chronic interpersonal stressors in the job (D'Layne West, 2018). Three key dimensions of this response are exhaustion, feeling of cynicism and detachment from the job and a sense of ineffectiveness and lack of accomplishment (Maslach & Leiter, 2016; D'Layne West, 2018).

Morita et al., (2004) explained that nurses are in continuous, direct and prolonged exposure to people who are dying or are hurt and these serve as a source of additional mental burden (Jaracz et al., 2017). In their study (Jaracz et al., 2017) observed that nurses experience greater intensity of job related stress than other human service professional like civil servants.

Garcia and Calvo (2011) based on their review of studies opined that nurses display a high level of emotional exhaustion (Laschinger & Finegan, 2008; Garcia & Calvo, 2011). Gunusen et al., (2014) cited Kowalski et al., (2010) who described emotional exhaustion as a feeling of excessive emotional stress and being drained by contact with other people (Gunusen et al., 2014). Researchers have described emotional exhaustion as the primary dimension of Burnout (e.g., Parker and Salmela-Aro, 2011; Lie et al., 2018). Kowalski et al., (2010) observed that in western countries between 15-40 percent of nurses working in hospitals suffer from burnout, Fiabane et al., (2013) stated the figure as 15-45 percent.

Based on Kulkarni (2006), Schaufeli et al., (2008) viewed that globalization, privatization, and liberalization have caused a fast change in modern work life. Demand for learning new skills, adapting to a different pattern of work, urge for higher productivity and quality, hectic job schedule, and time pressure may generate burnout in a fast-developing country like India.

Nurses in India operate in high power distance situations and are considered as subordinate in rank in the workplace. Hofstede et al., (2010) described Power Distance as the degree to which less powerful members of the organization accept and expect that power is distributed unequally in the organization. In Power Distant set up autocratic management is practiced and subordinates are expected to comply order of the superiors without question. Walton-Roberts (2012) observed one of the reasons for nurses' preference for a job outside India is their low status in India, they get more respect from doctors in the gulf and other countries. India is rated high in Power-Distance Index in Hofstede's Scale (Hofstede Center, 2014). Gill (2014) described in India Nurses are perceived as Assistants or Helpers to Doctors and do not enjoy professional importance as has been experienced by their counterparts in developed countries.

Burnout of Nurses apart from their increase in turnover also contributes to medical error. Garcia and Calvo (2011) viewed emotional exhaustion as a key factor that impacts nurses' quality of care to the patients. Alves and Guirardello (2016) also observed that emotional exhaustion impacts patient safety. Li et al., (2018) found Burnout is detrimental to achieve high-quality healthcare services and causes of loss in productivity.

Fairchild (2010) opined that the delivery of patient care is cumbersome and nurses need organizational support for maintenance of intrinsic motivation. Al- Homayan (2013) in his article cited the view of Bradley et al., (2005) that with organizational support nurses can continue their professional development and perception of more support likely to make them happy with their job. Perceived organizational support functions as a job resource in Job-Demands Resource Model (Wang et al., 2017), and serves as a coping resource. Pathak (2012) found in a sample of Indian managers that perceived organizational support intervenes in the relation between job stress and job satisfaction. Perceived organizational support functions as job resources following the JD-R model (Wang et al., 2017) and thus has a mitigating effect on job demands which serve as a cause of stress. Pisanti et al., (2011) in their study found that Italian Nurses perceive Job Characteristics, Organizational Conditions and Well-being more unfavorable than Dutch Nurses. Admi and Elton-Mashe (2016) observed different perceptions of stress from the same sources by Nurses of Thailand from that of Israel and the USA. Gyorkos et al., (2012) cited Lakshmi et al., (1999) regarding their study on perception of stress and coping strategies. In the study Lakshmi et al., (1999) observed that in USA work overload and lack of autonomy serve as major sources of stress whereas in India lack of clarity is the major source of stress. Knani (2013) found the implementation of new technology in an organization can have negative effects on employee's physical and mental health.

Hardly any study explains the influence of organizational support on the relationship between nursing role stress and emotional exhaustion of nurses in India and no such research can be traced which examined the effect of the feeling of low in professional status on emotional exhaustion of nurses. This study has been made among Nurses in the most populous city of India i.e. Kolkata to find out how significantly Nursing Role Stress relates to Emotional Exhaustion? How Nursing Role Stress influence Perceived Organizational Support? How Perceived Organizational Support influence the relationship between Nursing Role Stress and Emotional Exhaustion of Nurses? Do high power distance and low status add to the emotional exhaustion of nurses? This study seeks to explore these questions selecting nurses from different provinces of India employed in private hospitals of Kolkata.

Literature Review:
Nurses perform on behalf of the hospital for the interest of the patients' well-being and deliver a lot of emotional labor in these regards. Apart from psychological involvement voluminous workload for caring for allocated patients is handled by the nurses. According to Equity Theory (Adams, 1963; 1965) employees' job satisfaction and dissatisfaction depends on the outcome received against the inputs invested for work. Nurses being primary caregiver needs to put in a lot of labor in treatment of patients but in many events uncivil behavior of patient parties, excessive workload, blamed by the doctors off and on and even ignored by subordinate staffs (Dasgupta, 2014). All these create an imbalance between investment and return, exposure to these imbalance cause stress which eventually turns into emotional exhaustion the central dimension of Burnout. Nantsupawat et al., (2016) observed in samples of Thai Nurses that work environment has an important bearing on their Burnout. Job Demands Resources Model (Demerouti et al., 2001) and later on extended by several researchers state that excess job demands and less job resources exert an energy-draining effect on employees through a stressful process that may lead to Burnout (Hu et al., 2016). High workload, excessive demands from patients, uncertainty of treatment, suffering and death of patients Inspite dedicated service and continuous work as subordinate to doctors and administrative staff lead to a situation of high job demands. Continuous job demands without job control lead to physical and psychological depletion which is the state of Emotional Exhaustion. O'Connor e al., (2018) in their meta-analysis and systematic analysis of 33 studies found that work-related factors such as workload and relationship at work are key determinants of burnout.

It is hypothesized:
HI: Nursing Role Stress is significantly related to the Emotional Exhaustion of the Nurses. Nurses in India suffer from low status (Gill, 2011) and operate under high power distance situation which indicates their lack of control over the job. A stressor that may be present in the nursing role in India is low status and working in a high power distance situation, these serve as a deterrent in the smooth conducting of nursing activities. Nurses are the primary caregiver and spend maximum time with the patients. Considering their low status even subordinate staffs ignore them at times (Dasgupta, 2014) creating difficulty in rendering patient care. Dasgupta (2014) observed nurses are ridiculed by Doctors and Supervisors from time to time which they need to tolerate without protest.

In West, the job of nursing is synonymous with 'caring' and doctors with 'curing' of patients whereas in India nursing is considered low in status to doctors and administrative staffs and perform in high power distance situation. These may also be considered as a source of stress regarding conflict with Physicians and with Supervisory/ Administrative Staff and contributes to their emotional exhaustion.

It is hypothesized:

HII: High Power Distance and Low Professional Status serves as a source of Nursing Role Stress among Nurses in India and relates to their emotional exhaustion.
Higazeel et al., (2016) viewed nursing as a most stressful healthcare profession and described Perceived organizational support (POS) as the magnitude to which employees believe that their organization appraises their services and cares about their roles and the degree to which their needs are met by the organization (Higazeel et al., 2016; Dasgupta, 2015). When employees believe that the organization appreciates their effort and looks after at the time of need, positive emotion arises which serves as a mitigating factor on the effect of stress being felt out of the stressors hidden in the job. JD-R model suggests POS is a job resource that would alleviate the negative effect of emotional labor on burnout (Anomneze et al, 2016). This has been supported by Gramal and Baias (2018) in their study on the medical staff of Romania.

It is hypothesized:
HIII: Perceived Organizational Support is negatively associated with Emotional Exhaustion of the Nurses;
Whereas job demands are inherent in the role of nurses' job resources in the form of organizational support serves as a coping resource. A sense of reciprocation based on Social Exchange Theory (Blau, 1964) operates in the relationship between Nurses' Role Stress and Perceived Organizational Support i.e. fairness in treatment, caring healthcare administrators and colleagues, and employee-friendly organizational policies create negative effect on feeling of stress created due to the job demands inherent in the role of nurses. Death and dying of patients, unpredictable outcomes of treatment, dealing with the emotional reaction of patients' relations, excessive workload, and conflict with Doctors and Supervisors (Gray-Toft & Anderson, 1981) while discharging duty are some of the stressors inherent in the job of nurses. When the organization supports through fair policy and caring approach to nurses' effects of these deterrents reduce as nurses' experience an environment where they can do justice to their role freely with the feeling of being equal as others in the organization.

It is hypothesized:
HIV: Nursing Role Stress is negatively related to Perceived Organizational Support
Woodhead et al., (2014), in a study on nurses, found that greater job demands were associated with higher emotional exhaustion and sufficient job resources were linked to lower emotional exhaustion. Wang et al., (2017) viewed Perceived Organizational Support as job resources under the JD-R Model and opined POS may improve nurses' work attitudes. Scanlan and Still (2019) extended support to these findings as they observed that job resources like rewards and recognition, job control, feedback, and participation negatively relate to burnout and helps in developing a positive work attitude. Emotional demands and shift work are associated with the exhaustion component of burnout. Positive work attitude induced by organizational support work as a deterrent to the adverse effect of nursing role stress on the emotional exhaustion of nurses. When nurses experience recognition for good work, caring management, supportive doctors and Supervisors they enjoy a positive emotion which reduces their emotional exhaustion which would have otherwise caused due to these stressors.

It is hypothesized:
HV: Perceived Organizational Support mediates in the relationship between Nursing Role Stress and their Emotional Exhaustion
Following diagram shows the linkage mentioned in the hypothess

Perceived Organizational Support
Figure I: Hypothesized Relationship (Source: Hypothesis)
Note: Arrows indicate Direct Relation and Dotted Lines indicate Mediated Relationship Methodology
To determine the validity of Research Instruments, a Pilot Study was undertaken in which one hundred seventy-five nurses from three private hospitals in Kolkata participated. To maintain anonymity, the author did not include the name of the participants in Questionnaires; care was taken to see that all the nurses are in confirmed employment of the hospitals. Researchers adopted scales from the work of different authors; to see that the scale conveys the same meaning its original length was retained. To ensure that variance in numbers of different scales in the questionnaires does not confuse respondents interpretation of the varying value in scale was explained to them while conducting the survey. Researchers checked the reliability of the scales in the local context by measuring internal consistency (Zikmund, 1997).

Regarding Emotional Exhaustion (EE) Maslach et al., (1996) scale was tested by taking out 9 items related to emotional exhaustion. It is a 7-Point Scale where 0 indicates never and 7 as every day. Cronbach's Alpha of the sample identified as .929

For Nursing Role Stress (NRS) (Gray-Toft & Anderson, 1981a) scale was used. There are 34 items and it is a 4-Point Scale where 0= Never; 3= Very Frequently. To find specifically feeling out of low status and operating under high power distance situation statement of Item number 24 changed from "Criticism by a physician" to "Criticism by a physician and accepting silently"; Item No. 25 changed from "Conflict with a physician" to "Conflict with a physician and admitting mistake of self only because of difference in status"; Item No. 28 changed from "Disagreement concerning the treatment of a patient" to "Disagreement concerning the treatment of a patient and accepting Physician's version without debate"; Item No. 30 "Conflict with a supervisor" changed to "Conflict with a supervisor and admitting mistake of self only because of difference in status" and Item No. 33 "Criticism by a supervisor" changed to "Criticism by a supervisor and admitting mistake of self only because of difference in status." Cronbach's Alpha is .933.

Scale designed by Eisenberger et al. (1997) has been used about Perceived Organizational Support (POS). This scale runs from 1 to 7 where 1 indicates Strongly Disagree and 7 is Strongly Agree. Researcher found Cronbach's Alpha as .864

The Cronbach's Alpha for the measures was above 0.7 and is reliable (Nunnally, 1970). Once the survey instrument finalized, the researchers initiated the Main Study. The survey was undertaken in six private hospitals. To ensure voluntary participation Staff Nurses were explained about the Study and assured that strict confidentiality be maintained about their response and their name cannot be divulged as there is no provision of mentioning name in Questionnaire. Only Staff Nurses engaged in direct patient care were invited. Care has been taken to include nurses with origin in different states of India in the sample. To ensure homogeneity among the respondents, the researcher invited nurses who are in a regular service contract. Quota sampling mode was adopted and one-fifth of respondents taken from critical care and casualty, these units are usually considered more stressful. Five hundred twenty-five respondents took part and 506 Questionnaires were filled. SPSS .20 was used.

Results and Analysis: Descriptive statistics are given in Table I;

It shows that feeling of low status in comparison to doctors, supervisory and administrative staff in conflict situations is having the strongest relationship (Beta= .564, Sig. 000) with emotional exhaustion in comparison to other stressors.

Based on Respondent's feedback Pearson Correlation analysis indicates a significant relationship between Nursing Role Stress and Emotional Exhaustion (r= .705; sig.2-tailed .000); between Nursing Role Stress and Perceived Organizational Support (r=-.172; sig. 2-tailed .000) and between Perceived Organizational Support and Emotional Exhaustion (r= -.253; sig. 2-tailed .000). In all the events Correlation was significant at 0.01level (2-tailed). Researchers found that the result of the correlation was in order with the hypothesis. Multi-collinearity may not arise as correlations were not above .90(Myers, 1986)

Baron and Kenny (1986) about mediation opined that under-mentioned relationship must exist between Independent (IV), Dependent (DV) and Mediating Variables (MV): Firstly, Independent Variable needs to significantly influence Mediator (Baron & Kenny, 1986); Secondly, Relationship between Independent and Dependent Variables need to be significant (Baron & Kenny, 1986); Third, Relationship between Mediator and Dependent to be significant (Baron & Kenny, 1986); If these are in order, in case of mediation, the influence of IV on DV would reduce when MV intervenes. (Baron & Kenny, 1986) Perfect mediation holds if IV retains no significant influence on DV when MV intervenes. To analyze the relationship between Nursing Role Stress and Emotional Exhaustion, POS and Emotional Exhaustion, Nursing Role Stress and POS, mediation effect of POS on the relationship between Nursing Role Stress and Emotional Exhaustion researchers used multiple regression method. Findings have been given in Table III:

Explanation: Relation between Nursing Role Stress (IV) and Emotional Exhaustion (DV) (R Square .497; Adj. R Square .496 Betas .705). The F-test result is 497.491with a significance of .000. Regression of POS (IV) was on Emotional Exhaustion (DV). (R Square .064, Adj. R Square .062 Beta -.253). The F-test result is 34.507 with a significance of .000. Relationship between NRS (IV) and POS (DV) (R Sq.030, Adj. R Sq. 028, Betas -.172) F-Value 15.399 with significance .000; All these display Goodness of Fit.

In the analysis, the regression equation is significant at a 95 percent confidence level and it has been found that the probability of occurrence of these results is less than 0.001. It can be understood that a meaningful relationship is in place.

Relationship between NRS and Emotional Exhaustion is affected due to mediation by POS as the F-Test Result comes down from 497.491 to 266.680 and that of Beta from .705 to .681. Factor analysis undertaken shows that the percentage of the variance between NRS and Emotional Exhaustion reduced from 76.7 to 55.819

Sobel (1982) provided an approximate significance test for the indirect effect of the Independent Variable on the Dependent Variable via the Mediator (Baron & Kenny, 1986) and has been conducted.

Sobel test (Z-value = 5.677, p <.01) supported that POS mediated in the relationship between NRS and EE, Fig-II shows the Causal Relationship: Thus, this study conclusively tested and validated the following hypotheses: HI: Nursing Role Stress significantly relates to Emotional Exhaustion of the Nurses HII: High Power Distance and Low Professional Status serves as a source of Nursing Role Stress among Nurses in India and significantly relates to their Emotional Exhaustion. HIII: Perceived Organizational Support is negatively associated with Emotional Exhaustion of the Nurses; HIV: Nursing Role Stress negatively relates to Perceived Organizational Support This study has also partially validated: HV: Perceived Organizational Support mediates in the relationship between Nursing Role Stress and Nurses' Emotional Exhaustion

Perceived Organizational Support
Figure II: Relationship between NRS, POS, and EE
(Source: Data Analysis)
Note: Arrows indicate direct and Dotted Lines indicate mediation relationship

This Study shows that Perceived Organizational Support serves as a mitigating factor on the effect of nurses' role stress on their emotional exhaustion. Nursing Role Stress affects the physical, psychological, and social environment of the nurses which in turn causes their emotional exhaustion. Gray-Toft and Anderson (1981a &b) identified several sources of nurses' stress, feeling of stress arising out of nurses' conflict with doctors, supervisors and administrative staff is found to be most influential in affecting their emotional exhaustion. Scale designed by Gray-Toft and Anderson (1981a &b) identifying the stressors has been validated in different countries including countries characterized by high Power-Distance culture like India (Pathak et al., 2013). Nurses' in India is considered as low in status and also work under high power distance situation. In high power distance situations employees do not believe in initiating action (Zhang, 2010) and unethical behavior of superior often goes unnoticed (Ghosh, 2011). Unequal relationships in the healthcare sector create fear which harms the interest of the patient.

Mirsadeghi and Pazokian (2015) based on their review of studies in Iran observed that nurses out of fear from managers and educators are reluctant to report medication error. Iran has been rated as high though lower than India in power distance characteristics by Hofstede. Nursing involves continuous delivery of care, suppression of unintentional error apart from causing damage to patient's health which perhaps could be avoided if it would have been reported on time also cause guilty feeling among Nurses and serve as a cause of stress. Nurses in India which is characterized as power distance society might suffer from the same stressors different from that of countries with low power distance situations. Organizational Support in the form of reward for good work, autonomy, job security, supervisory support, feeling of fairness through procedural and distributive justice, training for the upliftment of skills and emotional stability, feeling of management support may create for a secured and cared physical environment for the nurses (Dasgupta, 2012). Organizational encouragement for creating a collaborative environment among doctor-nurse, nurse-nurse creates a friendly social environment in the workplace. All these serve as a deterrent to the role stress inherent in the job of nursing. Dewi et al., (2019) opined based on their study on nurses in Indonesia that organizational support is needed for good performance and to create a hospitable work environment of the nurses.

Perceived Organizational Support is particularly crucial for nurses serving in the metropolis in India, as most of them are from other states or districts of the same province. Most of these nurses stay in the nurses' hostel and may not be in a position to get immediate family support. As a result, they look at the organization not only for reward, fair, and just treatment but even for food, shelter, and moral support (Dasgupta, 2012). Connell (2010) opined that migrant employees look at employers for their day to day requirements (Dasgupta, 2012)

Thus, Organizational Support may control many of the stressors, improve patient care and patient safety (Alves & Guirardello 2016). But, the Job of Nursing has some stressors implicit in it (Keil & Hober, 2018) such as lack of feeling of reciprocity by some patients; the unpredictable outcome for treatment of patients, rude behavior of the patients' relations, etc. may not be controlled by Organizational Support.

Academic Implications
Establishing a partial mediation effect of Organizational Support in the relationship between Nursing Role Stress and Emotional Exhaustion in the context of Indian Nurses is an addition to the literature. Emotional Exhaustion is the result of high job demand involving emotional labor with unpredictable outcomes and inadequacy of job resources hidden in the role of nurses. The study Relationship between Nursing Role Stress and Emotional Exhaustion is found to be stronger with 76.7% variance than the sample of Nurses in Belgium conducted by Stordeur et al., (2001) which indicated a 22% variance. The cultural difference may be a reason for this variance and may also be attributed to the low status and high power distance situation within which Indian nurses perform. This study supports the findings of Kinman et al., (2011) who in a sample of teachers in the UK, found some evidence of organizational support mitigating the negative impact of emotional demands on emotional exhaustion. This study also gets support from the findings of Van Bogaert et al., (2013) who observed that unfavorably perceived organizational support predicts emotional exhaustion through nurse-reported workload and also from that of Van Bogaert et al., (2014) who stated that organizational support has bearing on nurses' feeling of burnout.

Gill (2011) and Walton-Roberts (2012) viewed less respect in the job is one reason for Indian nurses' migration abroad. Emotional exhaustion is an established reason for nurses' turnover (Dasgupta, 2015) and this study is contributing in that direction. An important finding of the study is the feeling of the low status of nurses regarding conflict with doctors, supervisors and administrative staffs serve as a major source for the generation of emotional exhaustion of nurses in India.

This finding is not in consonance to that of Labrague et al., (2018) who on a sample of nurses in the Philippines found no significant correlations between Perceived Organizational Support and Job Stress. Authors concluded that Perceived Organizational Support had been found low in the Philippines than other international studies. These factors may be a reason for Filipino nurses' extensive migration abroad. Several studies have concluded that lack of Perceived Organizational Support is a significant reason for turnover intentions and turnover of nurses (e.g., Fox, 2010; Rudman & Gustavsson, 2011).

Implications for Healthcare Managers:
This study has been undertaken to help Healthcare Managers to draw appropriate policy to control the emotional exhaustion of the nurses. Nurses comprise a significant working group of a hospital and are closely related to the treatment of the patients. Emotional exhaustion of the nurses adversely affects patient care and satisfaction. Words of satisfied patients and their relations are the most effective marketing tool of healthcare institutions, and these spread from satisfied patients and their relatives. Globally nursing shortage is a problem and acute in countries like India; burnout is a significant reason for the high turnover of nurses. Control of emotional exhaustion may help Healthcare Administrators to reduce the turnover of nurses apart from rendering better quality of care.

Limitations and Scope for Further Research:
Certain caveats on the study scope for further research have been discussed. Only nurses working in hospitals of Kolkata- the most populous city of India participated in the study; the researcher did not take into account any other metropolitan city. Researchers took care to include nurses of different linguistic origins in it. Taking a larger sample covering the hospital of another metropolis of India would have constructed a general opinion about nurses working in hospitals of the metropolitan cities in India.

This study showed a higher variance in the relationship between Nursing Role Stress and Emotional Exhaustion than that in a similar work conducted in Belgium. Nurses in Europe enjoy status at par with Doctors and Administrators (Cummings et al., 2009) whereas In Indian subcontinent nurses work in the high power-distance situation and lower in status (Dasgupta, 2014). This study has found conflict with doctors and administrative staffs a major driver of emotional exhaustion of nurses due to their low status, detailed research may explore this fact in several countries with the high power-distance environment.

Based on Quota Sampling Data has been collected from different units such as the ward, critical care, operation theatres, and cath lab. Job in the critical care unit is considered more stressful, and this might affect these outcomes. A separate study on each of the departments of the hospital may explore further.

Nursing considering its nature of work is susceptible to burnout which adversely affects quality of patient care, nurses’ well-being and is also a reason for turnover of nurses. Among the three dimensions of burnout emotional exhaustion is described as a central dimension. Study has indicated that causes and intensity of feeling of stressed varies between nurses of different countries. In India apart from those sources of stress being experienced by nurses of west also has implicit stressors of performing in low subordinate status under Power-Distance situation. Perceived Organizational Support has been found to contribute in lessening Nursing Role Stress and its influence on Emotional Exhaustion. Hence, study has been made to find out the effect on Nursing Role Stress on their Emotional Exhaustion and how Perceived Organizational Support impacts Nursing Role Stress does directly and indirectly on its effect on Emotional Exhaustion. This paper also examined the effect of different stressors on Nursing Role Stress. Study was conducted in six private hospitals in Kolkata in which 506 Nurses with origin in different provinces of India participated. Data was processed using correlation, regression analysis and mediation analysis was confirmed using Sobel Test. Result showed that Nursing Role Stress significantly relates to Emotional Exhaustion and Perceived Organizational Support partially mediate in the relationship. Feeling of low status and performing under Power-Distance situation serve as a major source of nursing role stress. Results, Academic implications, Implications for Healthcare Managers, Limitations and Scope for Further Research analyzed in the Study.

This study may be helpful for Healthcare Managers to devise appropriate policy for controlling emotional exhaustion of the nurses.


  1. Adams, J. S. (1963). Toward an understanding of inequity. Journal of Abnormal and Social Psychology, 67, 422-436.
  2. Adams, J. S. (1965). Inequity in social exchange. In L. Berkowitz (Ed.), Advances in experimental social psychology (Vol. 2, pp. 267-299). New \fork: Academic Press.
  3. Admi, H., & Elton-Mashe, Y. (2016). Do hospital shift charge nurses from different cultures experience similar stress? An international cross sectional study International journal of Nursing Studies, 63, 48-57, doi: 10.1016/j.ijnursli 2016.08.005. Epub. 2016 Aug. 26
  4. Al-Homayan, A.M., Shamsudin, F.M., Subramaniam, C. and Islam, R.(2013).Effects of Job Stress and Organizational Support on the Relationship between Job Demand Resources and Nurses’ Job Performance in Saudi Public Hospitals, Australian Journal of Basic and Applied Sciences, 7(10), 7-19
  5. Alves, D.F.S. and Guirardello, E.B. (2016). Safety climate, emotional exhaustion and job satisfaction among Brazilian pediatric professional nurses, International Nursing Review, 63(3), 328-335
  6. Anomneze1, E.A., Ugwu, D.L., Enwereuzor1, I.K., Ugwul, L.I. (2016). Teachers’ Emotional Labour and Burnout: Does Perceived Organizational Support Matter? Asian Social Science, 12 (2), doi:10.5539/ass.v12n2p9 URL: http://dx.doi.org/10.5539/ass.v12n2p9, 9-22
  7. Bradley, E., P. Campbell, P. and Nolan (2005) Nurse prescribers: Who are they and how do they perceive their role? Journal of Advanced Nursing, 51(5): 439-448.
  8. Bakker, A.B. and Demerouti, E. (2017). Job Demands-Resources Theory: Taking Stock and Looking Forward. Journal of Occupational Health Psychology at 20, 22(3), 273-285
  9. Baron, R. M., and Kenny, D. A. (1986).The moderator–mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality & Social Psychology, 51, 1173-1182
  10. Blau, P.M. (1964).Exchange and Power in Social Life. New York: John Wiley
  11. Connell, J. (2010). Pacific islands in the global economy: The paradoxes of migration and culture. Singapore Journal of Tropical Geography, 31(2), 115-129
  12. Cummings, G.C., Macgregor, T., Davey, M., Lee, H., Wong, C.A., Lo, E., … Stafford, E.(2009). Leadership styles and outcome patterns of nursing workforce and work environment: A systematic review. International Journal of Nursing Studies, doi:10.1016/j.ijnurstu.2009.08.006
  13. D’Layne West, D. (2018). An analysis of Principal Burnout and Job-Person Fit among Elementary, Middle and High School Principals in Alabama. Dissertation, Liberty University, Lynchburg, VA
  14. Dasgupta, P. (2012). Effect of Role Ambiguity, Conflict and Overload in Private Hospitals’ Nurses’ Burnout and Mediation through Self Efficacy, Journal of Health Management, 14(4), 513-534, DOI. 10.1177/0972063412468980
  15. Dasgupta, P. (2014) Nurses’ Intention to Leave: A Qualitative Study in Private Hospitals, Globsyn Management Journal, 8 (1&2), 77-87.
  16. Dasgupta, P. (2015). Turnover Intentions among Nurses in Private Hospitals: Antecedents and Mediators. Journal of Strategic Human Resource Management, doi.
  17. 10.21863/jshrm/2015.4.3.014
  18. Demerouti, E., Bakker, A. B., Nachreiner, F., & Schaufeli, W. B. (2001).The job demands– resources model of burnout, Journal of Applied Psychology, 86, 499–512.
  19. Dewi, Y.S., Hargono, R., and Rusdi, A.(2019). Factors correlated to job stress among ICU nurses. Jurnal Ners, 14(1), 23-27, doi.org/10.20473/jn.v.14i1.12125
  20. Eisenberger, R., Cummings, J., Armeli, S. and Lynch, P. (1997) Perceived organizational support, discretionary treatment, and job satisfaction Journal of Applied Psychology, 82, 812-820
  21. Fairchild, R.M. (2010). Practical ethical theory for nurses responding to complexity in care Nursing Ethics, 17(3): 353-362
  22. Fox, K.C. (2010). Mentor program boosts new nurses’ satisfaction and lowers turnover rate. Journal on Continuing Education in Nursing, 41(7), 311- 318
  23. Garcia, G.M., & Calvo, J.C.A. (2011). Emotional exhaustion of nursing staff: Influence of emotional annoyance and resilience. International Nursing Review, 1-7
  24. Ghosh, A. (2011) ‘Power distance in organizational contexts – a review of collectivist cultures’, Indian Journal of Industrial Relations, Vol. 47, No. 1, pp.89–101
  25. Gill, Reema. (2011). Nursing Shortage in India with special reference to International Migration of Nurses. Social Medicine, 6(1), 52-59
  26. Gill, Reema. (2014). International migration of skilled health workers: A case study of Indian nurses. Doctoral Thesis, New Delhi: Jawaharlal Nehru University
  27. Gramal, B.G., Baias, M. (2018). Organizational Support, Emotional Labour and Burnout regarding the Medical Staff. AMT, 23(1), 16-19
  28. Gray-Toft, P., and Anderson, J.G. (1981).The nursing stress scale: Development of an instrument. Journal of Behavioral Assessment, 3(1), 11-23
  29. Gray-Toft, P. and J.G., Anderson. (1981). Stress among hospital nursing staff: Its causes and effects. Social Science Medicine, 15, 639–647
  30. Gunusen, N.P., Ustun, B., and Erden, S.(2014). Work Stress and Emotional Exhaustion in Nurses: The Mediating Role of Internal Locus of Control. Research and Theory for Nursing Practice, 28(3), DOI. 10.1891/1541-6577.28.3.260
  31. Gyorkos, C., Becker, J., Massoudi, K., de Bruin, G.P., and Rossier, J.(2012). The Impact of Personality and Culture on the Job Demands- Control Model of Job Stress. Swiss Journal of Psychology, 71(1), 21-28
  32. Higazeel, M.Z.A, Rayan, A.& Khalil, M(2016). Relationship between Job Stressors and Organizational Support among Jordanian Nurses. American Journal of Nursing Research, 4(3), 51-55. Available online at http://pubs.sciepub.com/ajnr/4/3/1 ©Science and Education Publishing Doi. I: 10.12691/ajnr-4-3-1
  33. Hofstede, G., Hofstede, G.J. and Minkov, M. (2010) Cultures at Organisations: Nos Programmations Mentales, Pearson Education, France
  34. Hofstede Center (2014) [online] https://www.geert-hofstede.com (accessed 23 May 2015).
  35. Hu, Q., Schaufeli, W.B., Taris, T.W. (2016). Extending the job demands-resources model with guanxi exchange. Journal of Managerial Psychology Vol. 31 No. 1, 2016 pp. 127-140, DOI 10.1108/JMP-04-2013-0102
  36. Jaracz, M., Rosiak, I, Bertrand-Bucinska, A., Jaskulski, M., Niezurawska, J. & Borkowska, A. (2017). Affective temperament, job stress and professional burnout in nurses and civil servants. PLoS One, 12(6), e0176698. Published online 2017 Jun 6. Doi: 10.1371/journal.pone.0176698
  37. Keil, S., and Hober, C. (2018). Nurse Leader Initiative to Decrease Job Stress on the Acute Care Unit. International Journal for Innovation Education and Research, 6(12), 167-175, DOI: https://doi.org/10.31686/ijier.Vol6.Iss12.1266
  38. Kinman, G., Wray, S., and Strange, C. (2011). Emotional labour, burnout and job satisfaction in UK teachers: the role of workplace social support, Educational Psychology, 31:7, 843-856; http://dx.doi.org/10.1080/01443410.2011.608650
  39. Knani, M, (2013). Exploratory Study of the Impacts of New Technology Implementation on Burnout and Presenteeism, International Journal of Business Management, 8(22), 92-97
  40. Laschinger, H.K.S., and Finegan, J. (2008). Situational and dispositional predictors of nurse manager burnout: a time lagged analysis. Journal of Nursing Management, 16(5), 601-607
  41. Li, J., Han, X., Wang, W., Sun, G., Cheng, Z. (2018). How social support influences university students’ academic achievement and emotional exhaustion: The mediating role of self-esteem. Learning and individual Differences, 61, 120-126
  42. Kowalski, C., Ommen, O, Driller, E. Ernstmann, N., Wirtz, M.A., Thorster & Pfaff, H (2010) Burnout in nurses-the relationship between social capital in hospitals and emotional exhaustion, Journal of Clinical Nursing, 19, 1654-1663
  43. Kulkarni, G.K. (2006), “Burnout (Editorial)”, Indian Journal of Occupational and Environmental Medicine, Vol. 10, pp. 3-4
  44. Labrague, L.J., McEnroe Petite, D.M., Bogaert, P.V. and Tsaras, K. (2018).Perceptions of organizational support and its impact on nurses’ job outcomes, Nurs Forum, 1-8
  45. Li, H., Chang, B., & Zhu, X.P. (2018). Quantification of burnout in emergency nurses: A systematic review and meta-analysis. International Emergency Nursing, 19, 46-54
  46. Maslach, C., Jackson, S.E., & Leiter, M.P. (1996). Maslach Burnout Inventory Manual (3rd Ed.). Palo Alto, CA: Consulting Psychologists Press
  47. Maslach, C., and Leiter, M.P. (2016). Understanding the burnout experience: recent research and its implications for psychiatry. World Psychiatry, 15, 103-111
  48. Mirsadeghi, A., and Pazokian, M. (2015). Barriers to Reporting Medication Errors in Iran: A Systematic Review. International Journal of Medical Reviews, 2(4), 317-321
  49. Morita, T., Miyashita, M., Kimura, R., Adachi, I, Shima, Y. (2004). Emotional burden of nurses in palliative sedition therapy. Pall. Med., 18, 550-557
  50. Myers, Raymond H. (1986). Classical and Modern Regression with Applications, Boston, D
  51. Nantsupawat, A., Kunaviktikul, W., Nantsupawat, F.R., Wichaukhum, O-A., Thienthong, H. (2016). Effects of nurse work environment on job dissatisfaction, burnout, and intention to leave. International Nursing Review, https://doi.org/10.1111/inr.12342
  52. Nunnally, J. (1970). .Introduction to Psychological Measurement McGraw-Hill, New York, Oaks: CA.
  53. O’Connor, K., Neff, D.M., Pitman, S. (2018). Burnout in mental health professionals: A systematic review and meta-analysis of prevalence and determinants. European Psychiatry, 53(2018), 74-99
  54. Parker, P.D. & Salmela-Aro, K. (2011). Developmental Processes in School Burnout: A Comparison of major Developmental Models. Learning and Individual Differences, 21(2), 244-248
  55. Pathak, D. (2012). Role of perceived organizational support on stress-satisfaction relationship: An empirical study, Asian Journal of Management Research, 3(1), 153-177
  56. Pathak, V., Chakraborty, T. & Mukhopadhyay, S. (2013). Reliability and Validity Analysis of Modified Nursing Stress Scale for Indian Population. Journal of Nursing Measurement
  57. 21(2) Doi: 10.1891/1061-3749.21.2.224
  58. Pisanti, R., Van der Doef, M., Maes, S., Lazzari, D., and Bertini, M.(2011). Job characteristics,
  59. Organizational conditions, and distress/well-being among Italian and Dutch nurses: A cross-national comparison. International Journal of Nursing Studies, 48, 829-837, doi:10.1016/j.ijnurstu.2010.12.006
  60. Rudman, A. and Gustavsson, J.P. (2011).Early-career burnout among new graduate nurses: A prospective observational study of intra-individual change trajectories. International Journal of Nursing Studies, 48(3), 292-306.
  61. Scanlan, J.N., and Still, M.(2019). Relationships between burnout, turnover intention, job satisfaction, job demands and job resources for mental health personnel in an Australian mental health service. BMC Health Services Research, 19, 62 (2019). https://doi.org/10.1186/s12913-018-3841-z
  62. Schaufeli, W.B., Leiter, M.P. and Maslach, C. (2008). Burnout: 35 years of research and practice. Career Development International, Vol. 14 No. 3, pp. 204-220
  63. Stordeur, S., D’hoore, W. and Vandenberghe, C.(2001).Leadership, organizational stress, and emotional exhaustion among hospital nursing staff, Journal of Advanced Nursing, 35(4), 533-542
  64. Van Bogaert, P., Kowalski, C., Weeks, S.M., Van heusden, D., and Clarke, S.P. (2013). The
  65. Relationship between nurse practice environment, nurse work characteristics, burnout and
  66. Job outcome and quality of nursing care: A cross-sectional survey. International Journal of Nursing Studies, 50, 1667-1677, http://dx.doi.org/10.1016/j.ijnurstu.2013.05.010
  67. Van Bogaert, P., Timmermans, O., Weeks, S.M., van Heusden, D., Wouters, K., and Franck, E. (2014). Nursing unit teams matter: Impact of unit-level nurse practice environment, nurse work characteristics, and burnout on nurse reported job outcomes, and quality of care, and patient adverse events—A cross-sectional survey. International Journal of Nursing Studies (In Press).
  68. Walton-Roberts, M.(2012).Contextualizing the global nursing care chain: international migration and the status of nursing in Kerala, India. Global Networks, 12(2), 175-194
  69. Wang, X, Liu, L., Zhou, F., Hao, J., & Wu, H (2017). Associations of Occupational Stressors, Perceived Organizational Support, and Psychological Capital with Work Engagement among Chinese Female Nurses. BioMed Research International, 2017, 1-11, doi.org/10.1155/2017/5284628
  70. Woodhead, E.L., Northrop, L. and Edelstein, B. (2014). Stress, Social Support and Burnout among Long Term Care Nursing Staff, Journal of Applied Gerontology, 1-22, DOI: 10.1177/0733464814542465
  71. Zhang, Y. (2010). Power distance and its moderating impact on empowerment and team participation (HKIBS Working Paper Series 066-1011). Retrieved from Lingnan University website: http://commons.ln.edu.hk/hkibswp/53
  72. Zikmund, W.R. (1997). Business Research Methods (5t Ed.), the Dryden Press, Fort Worth, Texas