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directions in support of a leader in the promotion of a structured organization. 1-4 Nurses, as professionals, are part of this growing evolution.

1 Follow the leader: How does By Juanita Crawford, EdD, and Michael K. Daniels, PhD Workplace environments face challenges in developing structures that project and encourage professional followership the act or capability of effectively following instructions or directions in support of a leader in the promotion of a structured organization. 1-4 Nurses, as professionals, are part of this growing evolution. 1-4 Nurses regularly provide emotional support to patients suffering from pain due to traumatic illnesses, while at the same time facing opposition from administration and physiciancontrolled work environments concerning work ethics. 5 Continued opposition from leadership and additional stressors increase nurse burnout. 6-8 A study conducted on nurses in five countries found that 30% to 40% of nurses report feeling burned out. 9 Interestingly, another study indicated that 89% of nurses agreed: they re leaving the profession due to burnout. 10 Researchers contend that nurses are in need of better leadership that elicits effective followership. 11,12 Leaders strong in followership skills can enhance transformation of organizational outcomes. According to one expert, this transformation must begin with effective leader-followership exchange. 13 Throughout history, leaders have received recognition as the most important factor of organizational outcomes. Yet, followers, who represent 80% to 90% of organizations and are responsible for the overall productivity, don t receive worthy recognition A significant factor underlying these healthcare issues may be the relationship that followership plays on nurse burnout. 17 Method and design The purpose of this quantitative, cross-sectional observational survey study to investigate the followership styles of actively practicing RNs in southeastern Michigan. 13 The present study also examined how followership styles influenced burnout in healthcare environments. The current research study employed two established surveys that specifically measured followership style (the independent 30 August 2014 Nursing Management nursingmanagement.com

2 followership influence nurse burnout? nursingmanagement.com Nursing Management August

3 Follow the leader variable) with multiple levels: exemplary, alienated, conformist, pragmatic and passive, and nurse burnout (the dependent variable) as manifested in three subscales: emotional exhaustion, depersonalization, and personal accomplishment. In addition, this current research study examined 114 randomly selected RNs gender, age, and years of experience (demographic variables) in relationship to their burnout. (See Table 1.) The Kelley Followership Questionnaire measured the nurses followership styles (exemplary, alienated, conformist, pragmatist, and passive). 13 The Maslach Burnout Inventory, which measures burnout in the subscales emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA), measured the nurses burnout levels and demographic variables. 18,19 The research questions used in this study were: 1. What relationship, if any, exists between followership style and nurse burnout? 2. What s the relationship between the nurses demographics (gender, age, and years of experience) and burnout? The research questions were derived from a review of the data in the literature suggesting that followership styles influence followers productivity and that nurses gender, age, and years of experience may influence nurse burnout. 13 Ironically, the literature suggests that nurses working in healthcare environments demonstrate the traits and skills necessary for good followership but often lack the capacity to reach goals because of negative forces fighting against them. 20,21 Although leaders are an important part of the healthcare team, negative characteristics of leaders have been noted in the literature. Leaders acts of disrespecting, disvaluing, discrediting, and Table 1: Chi-square of the five followership styles and the burnout subscales (N = 114) F-styles EE subscale Low Moderate High Total Test-stat (P-value) Exemplary X 2 (8, N = 114) = 4.75, P =.78 Alienated Conformist Pragmatist Passive Total % 39.5% 22.8% 37.7% 100.0% DP subscale Exemplary X 2 (8, N = 114) = 10.26, P =.24 Alienated Conformist Pragmatist Passive Total % 69.3% 14.9% 15.8% 100.0% PA subscale Exemplary X 2 (8, N = 114) = 29.56, P <.01 Alienated Conformist Pragmatist Passive Total % 68.4% 21.1% 10.5% 100.0% Note: N = 114; the burnout scores in the PA subscale are reversed the higher the score, the less the burnout experienced. 32 August 2014 Nursing Management

4 overworking followers in healthcare organizations often compound nurse burnout. 22 Therefore, there s a strong need in healthcare organizations for leaders to develop and promote the essentials of valuable and exemplary followers, specifically in the area of nurse autonomy. 20,23 This current research study systematically investigated whether a better understanding of followership style helps minimize nurse burnout. The research questions generated the research hypotheses. Positive or negative connotation? Followership is the essential building block in the endorsement of authority given to leaders. 24 The dynamics of leadership closely relate to followership, and society is in need of strong, efficient leaders to integrate the essentials of effective and successful followers In all organizations, leadership and followership roles are essential, and both followers and leaders must work congruently toward the organizational purpose. 25,29,30 Just as leaders possess various leadership skills and styles to become effective leaders, followers possess various skills and styles to become effective followers. 23 Although society agrees that leaders and followers are important, research confirms that many people continue to assign negative associations with the word follower/followership. 13,31 Hypotheses This current research study used a quantitative, cross-sectional, observational design employing two established, self-administered, closed-question mailed surveys to investigate the degree of association between followership styles and nurse burnout. The research questions were tested employing statistical procedures. This section includes a rationale for the demographic variables and followership variables employed to address the research questions. The demographic hypotheses addressed the relationship between nurses burnout and gender, age, and years of experience. Reports in the literature suggest there are variations in regard to gender, age, and years of experience in relationship to nurse burnout. According to one researcher, female healthcare workers tend to report higher levels of burnout. 32 However, other experts theorized that both genders of healthcare workers suffer a significant amount of burnout. 33 Hypothesis 1 (H1) of this study investigated whether there s an association between gender and burnout. According to the American Federation of State, County, and Municipal Employees, younger nurses may leave healthcare organizations for reasons related to burnout. 34 The age hypothesis 2 (H2) explored the association between age Finally, hypothesis 3 (H3) evaluated the association of years of experience and burnout, since reports in the literature suggest that new nurses may burnout at higher rates than senior nurses. 33 The study hypotheses for the demographic values were as follows: H1 0 between nurse gender H1 a between nurse gender H2 0 between nurse age H2 a between nurse age H3 0 between nurse experience and burnout. H3 a between nurse experience and burnout. Followership variables The followership hypotheses addressed the relationship between nurses followership style and burnout. This current research study s five categories and measures of followership are based on the seminal work of leading expert Robert Kelley. 13 An alienated follower is someone who consistently points out all the negative facets of the organization to others. Conformists are followers who are low in independent thinking and high in active engagement. Kelley suggests that conformists take orders eagerly, defer to the leader s authority, and are submissive to the leader s judgment. Exemplary followers are individuals who effectively and willingly take on tasks and assignments with confidence. Passive followers are individuals who are low in active engagement and independent thinking, such as a person who depends on the leader, doesn t carry out his or her responsibilities, and requires constant direction and attention. Finally, a pragmatic follower is someone who performs work tasks only when instructed to do so, without challenging if the task is the appropriate thing to do. 35 Reports in the literature suggest that exemplary nurse followers may suffer little burnout by acquiring jobs with more autonomy. On the other hand, burnout may occur in alienated nurse followers because of their loss of interest in their jobs as caused by working in high stress environments. 36 Conformist nurse followers as yes people may be at risk for burnout related to accepting excessive obligations that can rarely be met and pragmatist nurse followers (not taking themselves seriously) may suffer from increased emotional tension related to inadvertently Nursing Management August

5 Follow the leader causing problems while working in undesirable work environments. 35,37 The literature suggests that passive nurse followers may suffer from increased burnout related to blindly following the leader without questioning important tasks resulting in poor outcomes. 38 Hypothesis 4 looked for significant burnout across the five followership styles: H4 0 in nurses burnout based on their followership style. H4 a in nurses burnout based on their followership style. Hypotheses 5 through 9 more carefully examined the specific effect of each of Kelley s followership styles: H5 0 between exemplary nurse followership H5 a between exemplary nurse followership H6 0 between alienated nurse followership H6 a between alienated nurse followership H7 0 between conformist nurse followership H7 a between conformist nurse followership H8 0 between pragmatist nurse followership H8 a between pragmatist nurse followership H9 0 between passive nurse followership H9 a between passive nurse followership Findings Based on the results of the analyses, there were statistically significant relationships between the five followership styles in relationship to the burnout subscale PA. Gender also related to PA scores. In addition, age and years of experience were related to DP. Linear regression results revealed a statistically significant correlation in a dichotomy between the exemplary and pragmatist followership styles and the burnout subscale PA. The results of the study are summarized below according to each group of research questions and their concomitant hypotheses. Null hypotheses 4, 5, and 6 Based on results for research question 1, null hypothesis H4 0 rejected and alternative hypothesis H4 a supported. There a statistically significant relationship between the nurses amalgamation of the five followership styles and PA. Based on results for research question 1, null hypothesis H5 0 rejected and alternative hypothesis H5 a supported. There statistical significance between exemplary nurse followership style and PA. Based on results for research question 1, null hypothesis H6 0 rejected and alternative hypothesis H6 a supported. There statistical significance between alienated nurse followership style and PA. Null hypotheses 7, 8, and 9 Based on the results for research question 1, null hypothesis H7 0 supported and alternative hypothesis H7 a rejected. There no statistically significant association between conformist nurse followership style and the three burnout subscales: EE, DP, or PA. Based on results for research question 1, null hypothesis H8 0 rejected and alternative hypothesis H8 a supported. There a statistically significant association between pragmatist nurse followership style and PA. Based on results for research question 1, null hypothesis H9 0 supported and alternative hypothesis H9 a rejected. There no statistically significant association between passive nurse followership style and EE, DP, or PA. Null hypotheses 1, 2, and 3 Based on results for research question 2, null hypothesis H1 0 rejected and alternative H1 a supported. There a marginally significant association between nurse gender and PA scores. Based on results for research question 2, null hypothesis H2 0 rejected and alternative hypothesis H2 a supported. There a statistically significant association between age and DP. Based on results for research question 2, null hypothesis H3 0 rejected and alternative hypothesis H3 a supported. There a statistically significant association between nurse experience and DP and PA. The results showed that there no statistically significant association between exemplary or pragmatist followership styles and EE or DP, but a statistically significant association between the exemplary and pragmatist followership styles and PA. A salient point derived from chisquare and linear regression results involving research question 1, which pertained to the independent variable followership style (levels of exemplary and pragmatist), and PA. The results showed no statistically significant association between age and PA, but there a statistically significant association between years of experience and PA. However, a salient point derived 34 August 2014 Nursing Management

involves research question 2, which pertained to the demographic variables age and years of experience and the dependent variable PA, which also included the linear regression findings.

Unquestionably, nurses not working at an optimal level of prudence pose a major threat to themselves, their patients, and their healthcare organizations since nurses are viewed as being at the

39-43 Indisputably, nurses must function at their highest level of prudence if they re to assist physicians with critical orders in the promotion of effective patient outcomes.

patient ratio, which may ultimately lead to patients deaths.

Leaders in healthcare organizations should be attentive to diminutive as well as constellating levels of burnout while developing and implementing tactics in relationship to (a) precepting,

6 involves research question 2, which pertained to the demographic variables age and years of experience and the dependent variable PA, which also included the linear regression findings. Ethical implications Nurses optimal level of prudence degenerates because of burnout, causing their work to be less productive or unproductive in healthcare organizations. Unquestionably, nurses not working at an optimal level of prudence pose a major threat to themselves, their patients, and their healthcare organizations since nurses are viewed as being at the forefront of patient care and safety, and are considered the force of hospitals Indisputably, nurses must function at their highest level of prudence if they re to assist physicians with critical orders in the promotion of effective patient outcomes. Prudence at optimal levels is specifically warranted for nurses working on surgical units in which burnout levels are higher because of excessive mandated overtime, nursing shortage, and higher patient ratio, which may ultimately lead to patients deaths. 44 The prevalence of nurse burnout has caused nurses to leave the profession at an alarming and increasing rate, adding to the existing nurse shortage. Leaders in healthcare organizations should be attentive to diminutive as well as constellating levels of burnout while developing and implementing tactics in relationship to (a) precepting, assessing, and validating burnout in nurses; (b) mediating on the behalf of nurses confirmed with burnout; (c) providing needed services for nurses with symptoms of burnout; and (d) formulating a prophylactic regimen for burnout. It s reasonable to expect that because of the prevalence of burnout in healthcare organizations, healthcare leaders, instead of deliberating cost-containment, should invest in implementing research (as studies are lacking) to enhance burnout intervention strategies in hopes of reducing or eliminating burnout, since higher expenditures are projected with replacing burned out nurses and answering grievances from poor patient outcomes. 39,45 Incontestably, the reduction of burnout and its diverse manifestations may enhance the leader-followership exchange; improve nurse and physician relationships; augment the productivity of healthcare organizations; and lead to enhancement in the care and health of patients, nurses, and the community. This current research study has met its goal in filling the gap in research on this topic. The literature supports the notion that ineffective leader-follower exchange among other high stressors in organizations healthcare environments increases nurse burnout, although no literature available to support if followership styles were an indicator of high or low exhaustion levels in nurses. The results of this current study on the influence of followership and nurse burnout heightens the importance of examining followership styles and burnout levels of nurses nationwide in healthcare environments. The findings of this current research study demonstrated that the nurses working in the healthcare environments in southeastern Michigan are suffering significant levels of burnout in the subscales DP and PA. These findings suggest that effective leader-followership exchanges (in Effective followership in nursing can potentially decrease burnout symptoms of practitioners. promoting motivational, supportive, and collaborative work environments) can strengthen nurse followers and may decrease nurse burnout. The outcome of the study prompts healthcare leaders, managers, nurse associations leaders, and nursing staff to collaborate in seeking positive changes in healthcare environments through legislation for better working conditions and policies. Although some nurses leave the nursing profession because of burnout, the literature suggests that some remain while coping with burnout. Therefore, nurse leaders in support of nurse empowerment, satisfaction, and retention must assess and make sure resources are available to assist nurses in coping with burnout. The practice of effective followership in nursing and other professions can be enhanced and potentially decrease burnout symptoms of practitioners. Leadership, on the other hand, may be enhanced by followers. Further, in the midst of the large Nursing Management August

7 Follow the leader nursing shortage and projected shortages, healthcare leaders and organizations may find it prudent to question the influence of followership in relation to nursing students as well as nursing instructors. Future research on the influence of burnout on nursing students and nursing instructors in relation to the highly stressful demands in nursing schools, perceptions of nursing school experience as valuable or discouraging in relationship to burnout, and the influence of burnout on the decision to quit or continue pursuing studies in pursuit of a degree or nursing instructorship may provide insight on effective recruitment and retention strategies for the viability of the nursing profession. Leaders and followers, unite Data from this current study revealed statistical significance between the followership styles exemplary and pragmatist and the burnout subscale PA. Statistical significance found between the nurse demographics of age and years of experience and the burnout subscales DP and PA. The findings from this current research study converge with researchers who contend ineffective followership and diverse burnout manifestations are critical to any organization, specifically, healthcare, when nurses and all who encounter care are affected. 46 The results of this study may assist healthcare leaders to develop awareness and understanding concerning the importance of professional followership; influence educational practices that motivate, support, and strengthen followers; and enhance nurses perceptions of their followership styles in relation to burnout. In addition, the findings of this study may inspire healthcare leaders and staff members to collaborate in seeking positive changes in healthcare environments perhaps through legislative efforts or other collaborative efforts. Raising awareness of the matter through positive communication is an important part of gaining understanding of ourselves as people contributing to the common goal of improving the health of ourselves and the community. NM REFERENCES 1. Heskett J. How much of leadership is about control, delegation, or theater? 2. Clemmer J. Follow the follower? Print Professional. 2007;45: Kaminski J. A professional development initiative. com/writings.html. 4. Dunn PJ. Addressing nurse burnout. Nursing made Incredibly Easy. 2012;10(4): Cohen-Katz J, Wiley SD, Capuano T, Baker DM, Shapiro S. The effects of mindfulnessbased stress reduction on nurse stress and burnout: a quantitative and qualitative study. Holist Nurs Pract. 2004;18(6): Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288(16): Department for Professional Employees. 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8 nurses at university hospitals. Japan Journal of Nursing Science. 2006;3(2): American Federation of State, County, & Municipal Employees. Listening to nurses: dissatisfaction and burnout on the job Walsh K. Leadership reflection paper. getportfoliofile?uid= Woods MS. Dr. Woods speaks Armstrong F. Safe staffing saves lives. Aust Nurs J. 2006;13(10): Habel M. Spread your wings: RNs have what it takes to be effective leaders. nursingspectrum.com/ce/ self-study_modules/course.html?id= McIntyre J. Penn research finds more patients die in hospitals with lower staffing. PennNursing_JAMA_ pdf. 40. Price C, Sebold C. ANA calls on policymakers to act on nurse staffing legislation. pr0110.htm. 41. Smith M, Jaffe-Gill E, Segal J, Segal R. Preventing burnout: signs, symptoms, and strategies to avoid it Taylor NT. The magnetic pull: administrators share how their facilities gained magnet status. Nurs Manag. 2004;35(1): World Health Organization. Gender, health, and work. health/gender, HealthandWorklast.pdf. 44. Garrett C. The effect of nurse staffing patterns on medical errors and nurse burnout. AORN J. 2008;87(6). 45. Maslach C. Test developed: the Maslach burnout inventory. com/mayfieldpub/psychtesting/ profiles/ maslach.htm. 46. Penn Nursing Science. Long shifts lead to nurse burnout and dissatisfied patients. Long-Shifts-Lead-to-Nurse-Burnout-and-. Juanita Crawford is an adjunct nursing professor at Wayne County Community College in Detroit, Mich. Michael K. Daniels is faculty at the University of Phoenix s School of Advanced Studies in Phoenix, Ariz. The authors have disclosed that they have no financial relationships related to this article. DOI /01.NUMA Nursing Management August

Burnout Among Health Care Professionals

Burnout Among Health Care Professionals NAM Action Collaborative on Clinician Well-being and Resilience Research, Data, and Metrics Taskforce Lotte Dyrbye, MD, MHPE, FACP Professor of Medicine & Medical