Safety and Health at Work 11 (2020) 88e96

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Safety and Health at Work

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Original Article

Mediating Effects of Burnout in the Association Between Emotional

Labor and Turnover Intention in Korean Clinical Nurses
Chi-Yun Back 1, Dae-Sung Hyun 2, Da-Yee Jeung 3, Sei-Jin Chang 4, *
1
Department of Preventive Medicine, Wonju College of Medicine, Yonsei University, Wonju, South Korea
2
Department of Biostatistics & Computing, Graduate School of Yonsei University, Seoul, South Korea
3
Department of Dental Hygiene, Hanyang Women’s University, Seoul, South Korea
4
Department of Preventive Medicine and Institute of Occupational & Environmental Medicine, Wonju College of Medicine, Yonsei University, Wonju, South
Korea

a r t i c l e i n f o a b s t r a c t

Article history: Background: The current lack of the number of nurses and high nurse turnover rate leads to major
Received 9 August 2019 problems for the health-care system in terms of cost, patient care ability, and quality of care. Theoreti-
Received in revised form cally, burnout may help link emotional labor with turnover intention. The purpose of this study was to
10 December 2019
investigate the mediating effect of burnout in the association between emotional labor and turnover
Accepted 14 January 2020
intention in Korean clinical nurses.
Available online 22 January 2020
Methods: Using data collected from a sample of 606 nurses from six Korean hospitals, we conducted a
multiple regression analysis to determine the relationships among clinical nurses’ emotional labor,
Keywords:
Burnout burnout, and turnover intention, looking at burnout as a mediator.
Clinical nurses Results: The results fully and partially support the mediating role of burnout in the relationship between
Emotional labor the subfactors of emotional labor and turnover intention. In particular, burnout partially mediated the
Turnover intention relationship between emotional disharmony and hurt, organizational surveillance and monitoring, and
lack of a supportive and protective system in the organization. In addition, we found that burnout has a
significant full mediation effect on the relationship between overload and conflicts in customer service
and turnover intention. Although the mediating effect of burnout was significantly associated with the
demands and regulation of emotions, no significant effects on turnover intention were found.
Conclusion: To reduce nurses’ turnover, we recommend developing strategies that target both burnout
and emotional labor, given that burnout fully and partially mediated the effects of emotional labor on
turnover intention, and emotional labor was directly associated with turnover intention.
Ó 2020 Occupational Safety and Health Research Institute, Published by Elsevier Korea LLC. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction the sake of improving job performance. An important aspect of

emotional labor is emotional distortion, which has been shown
Care is the core of nursing practice [1]. Nurses must forge a to influence workers’ mental well-being adversely by prompting
caring relationshipdas opposed to a simple task-oriented them to neglect their true emotions and inducing a sense of
onedwith patients in pain, which can render them emotionally alienation from oneself [3].
exhausted and may produce conflict. Despite this, nurses must The current world wide lack of nursing occupations has been a
demonstrate appropriate emotional management when current big issue in the past decade [4]. In 2002, the Bureau of Labor
providing services to patients face-to-face [2]. In other words, Statistics projected that the United States would be 800,000
nurses must engage in emotional labor [3], which pertains to registered nurses short of the national requirement by 2020 [5].
controlling one’s emotions and emotional display to accomplish Several researchers have suggested that withdrawal behaviors
an organization’s goals. More specifically, it refers to efforts to among nurses maybe an outcome of emotional labor. For example,
display the emotions that are deemed appropriate for the job, for Nixon et al. [6] argued that emotional labor could increase

* Corresponding author. Department of Preventive Medicine and Institute of Occupational & Environmental Medicine, Wonju College of Medicine, Yonsei University, 20
llsan-ro, Wonju, Gangwon-do, South Korea.
E-mail address: chang0343@yonsei.ac.kr (S.-J. Chang).

2093-7911/$ e see front matter Ó 2020 Occupational Safety and Health Research Institute, Published by Elsevier Korea LLC. This is an open access article under the CC BY-NC-
ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
https://doi.org/10.1016/j.shaw.2020.01.002
 C.-Y. Back et al / Mediating Effects of Burnout 89

psychological stress in the workplace, which in turn can have 2.2.2. Burnout
negative outcomes such as the intention to quit. Burnout was assessed using the 5-item scale developed by
Notably, turnover intention had a stronger correlation with Maslach and Jackson [11]. Each item was measured on a 4-point
burnout than with job stress. Nurse turnover is especially detri- Likert scale ranging from 1 (“not at all”) to 4 (“very often”).
mental for hospitals not because of the turnover per se but because Higher total scores on this measure indicate a higher degree of
it leads to considerable financial loss, undermines the quality of burnout. The following is an example item: “I feel exhausted
patient care, demoralizes fellow employees, and reduces efficiency because of my work.” In the present study, the Cronbach’s a was
and productivity [7]. 0.91.
Burnout is a negative psychological experience that often chal-
lenges workers whose job duties are highly interpersonal and who 2.2.3. Turnover intention
face prolonged exposure to stressors without adequate organiza- Turnover intention was measured using a tool developed by Kim
tional support. According to Maslach et al. [8], burnout is a psy- [12]. Kim [12] validated the scale using an expert panel, for use with
chological syndrome encompassing the aspects of emotional hospital nurses. The scale comprises six items measured on a 5-
exhaustion, depersonalization, and low personal achievement. In point Likert scale ranging from 1 (“not at all”) and 5 (“very
particular, organizational employees are exhausted if they are much”). A higher total score indicates a higher degree of turnover
exposed to chronic situations forcing emotional regulation. As a intention. The following is an example item: “If I could choose other
way of coping with emotional exhaustion, they may express hospitals to work at, I would not choose this hospital.” The Cron-
negative attitudes or behaviors toward the customers and bach’s a for this tool 0.79 in the present study, whereas that in
demonstrate dehumanizing and heartless responses, which in turn Kim’s [12] study was 0.76.
can lead to poor job performance and a negative assessment of
themselves [9].
The aim of this study was to determine whether the relationship 2.3. Research hypothesis
among clinical nurses’ emotional labor, burnout, and turnover
intention. Overall, emotional labor, job stress, and burnout all appear to be
key determinants of turnover intention among nurses [13,14]. In
particular, the positive correlation between emotional labor and
2. Materials and methods
turnover intention has been demonstrated. Grandey [15] also
suggested that emotional management increases physiological
2.1. Participants and procedure
arousal, which may lead individuals to withdraw from their work
and eventually quit. The following hypotheses were therefore
Study participants were nurses working at one of six general
proposed.
hospitals located in Seoul or Gangwon Province. Data were
collected using a self-administered questionnaire. A total of 606 Hypothesis 1. Emotional labor is positively related to turnover
registered nurses (response rate 60.6%) were included in the final intention.
analysis, after excluding 24 questionnaires for incomplete re-
It is important to note that, in the present study, the concep-
sponses. This descriptive cross-sectional study was performed to
tualization of emotional labor developed by Schaubroeck and Jones
examine the relationship of emotional labor and burnout to turn-
[2] was used, which includes emotional demands to regulate pos-
over intention in clinical nurses.
itive or negative emotion. As nurses may try to suppress negative
and to express positive emotions on a day-to-day basis [16], we
2.2. Measures have combined them to examine the composite effect of emotional
labor.
2.2.1. Emotional labor Meanwhile, many preceding studies have emphasized on
The Korean Emotional Labor Scale (K-ELS) [10] was used to burnout as an important factor influencing turnover intention
assess emotional labor. This 24-item scale comprises five subscales, [17,18]. Bartram et al. [17] actually demonstrated that burnout fully
including five items for emotional demand and regulation, three for mediated the relationship between emotional labor and intention
overload and conflict in customer service, six for emotional dishar- to leavedin other words, emotional labor results in burnout, which
mony and hurt, three for organizational surveillance and monitoring, in turn results in nurses wanting to leave their workplace. However,
and seven for lack of a supportive and protective system in the or- these past studies did not look at the various components of
ganization. Each item is measured on a 4-point Likert scale ranging emotional labor. More precisely, to ensure that intervention stra-
from 1 (“not at all”) to 4 (“very often”). The total summed score for tegies aimed at reducing turnover intention rate are effective, it is
the five subfactors ranges from 24 to 96, which are converted to a essential to understand which aspects of emotional labor are direct
0e100 scale for analysis. Higher total scores indicate a greater de- risk factors for turnover intention, and which maybe mediated by
gree of emotional labor. The following is an example item: “I burnout. Although there is numerous evidence that emotional la-
intentionally try not to express negative feeling to patient.” The bor can be stressful and can lead to burnout, a growing body of
Cronbach’s a coefficients for the five factors of emotional labor research has rarely considered the different impacts of emotional
ranged from 0.761 to 0.904 in the present study. To confirm the labor as the eligible risk factors of burnout and turnover intention.
factor structure of the K-ELS in our sample, we performed a prin- Through the present study, we aimed to fill this research gap.
cipal component factor analysis with a varimax rotation. The results
Hypothesis 2. Burnout mediates the relationship between
revealed five factors with eigenvalues of 1.00 or greater. Together,
emotional labor and turnover intention.
these factors explained 61.9% of the variance. All items loaded onto
at least one factor with factor loadings of 0.50 or higher. Further- The basis of our investigation of the associations between
more, the communalities for all items exceeded 0.50. Thus, the K- emotional labor, burnout, and turnover intention among clinical
ELS was deemed to have satisfactory factorial validity in our nurses was “the dissonance theory of emotional labor.” In accor-
sample. dance with the dissonance theory of emotional labor, which seems
90 Saf Health Work 2020;11:88e96

to be driven by the mediating influence of self-alienation (i.e., Table 1

emotional dissonance) [19], burnout maybe a crucial mechanism Distributions and mean values of participants' demographics (n¼606)

for demonstrating the relation of emotional labor to turnover Features Category n (%) M  SD
intention. A potential mechanism of this relationship is that hold- Sex Male 25 (4.1)
ing competing emotions creates a sense of emotional exhaustion, Female 581 (95.9)
which in turn motivates withdrawal behaviors, such as turnover Age (years) 20e29 291 (48.0)
30e39 219 (36.1)
intention [20]. Indeed, there is evidence that the emotional
40e49 91 (15.0)
exhaustion component of burnout is associated with turnover 50e59 5 (0.8)
intention [21] and voluntary turnover [22]. Morris and Feldman Marital status Single 358 (59.1)
[23] argued that the emotional workers gradually experience Married 248 (40.9)
burnout as their available capacity for emotional dissonance. Zapf Religion No 243 (40.1)
Yes 363 (59.9)
[19] also proposed that emotional dissonance positively affects
Education 3-year college 124 (20.5)
burnout. 4-year university or higher 482 (79.5)
Working department General wards 243 (40.1)
2.4. Data analysis ICU/OR/others 296 (48.8)
ER/outpatient 67 (11.1)
Position Staff nurse 538 (88.8)
The data were analyzed using SPSS Statistics 21.0 (IBM Corp.,
Charge nurse or higher 68 (11.2)
Armonk, NY). The participants’ demographic characteristics were
Clinical experience (years) 1e5 261 (43.1)
expressed in frequencies and percentages or means and standard 6e15 206 (34.0)
deviations. Pearson’s correlation analysis was performed to 16e34 128 (21.1)
examine the correlations between emotional labor, burnout, and Job type Shift 503 (83.0)
Ordinary hours 103 (17.0)
turnover intention. Simple and multiple regression analyses were
Experience of transfer Yes 351 (57.9)
performed to identify the mediating role of burnout in the rela- of department No 255 (42.1)
tionship between emotional labor and turnover intention; this Patient care hours 1e4 223 (36.8)
finding was validated using the 3-step mediation analysis method 5e12 369 (60.9)
developed by Baron and Kenny [24]. This causal-steps approach to Average weekly working hours 32e40 173 (28.5)
testing mediation entails a specific sequence of tests to examine the 41e49 191 (31.5)
50e60 242 (39.9)
relationships among the variables, making it suitable for analysis
OR ¼ operating room, ICU ¼ intensive care unit, ER ¼ emergency room.
[25].
In accordance with this method, mediation effects are consid-
ered present if the following conditions are met: (1) the indepen- 3. Results
dent variable significantly predicts the dependent variable; (2) the
independent variable significantly predicts the mediating variable; 3.1. Demographic characteristics of the study participants
and (3) when the dependent variable is regressed simultaneously
on the independent variable and the mediator, the mediator The participants were predominantly female (95.9%) and most
significantly predicts the dependent variable, and the independent fell in the 20e29 years age group (48%). Of them, 59.1% of the par-
variable has a weaker effect on the dependent variable than that ticipants were single, whereas 59.9% (n ¼ 363) had a religious
obtained in Condition 1. If the independent variable still has a affiliation. In addition, 79.5% had completed a 4-year university or
significant effect in Condition 3, the mediation is partially consid- higher degree. Most of the participants worked in the intensive care
ered; if the independent variable has a non-significant effect, the unit, operating room, or other departments (48.8%), followed by
mediation is deemed as full. Notably, however, Baron and Kenny general wards (40.1%), and emergency rooms, and outpatient clinics
[24] mentioned that only Condition 2 and 3 are needed to (11.1%). Participants were predominantly staff nurses (88.8%).
demonstrate mediation effects. The statistical significance of the Furthermore, most participants had 1e5 years (43.1%) of clinical
mediating effect was validated using the Sobel test. We adjusted for experience, followed by 6e15 years (34%) and 16e34 years (21.1%).
Type I error using Bonferroni corrections, and difference with a Most participants worked in shifts (83%), and they had been trans-
p < 0.01 was considered statistically significant. ferred to different departments in the past (57.9%). Approximately,
61% of the participants engaged in 5e12 hours of patient care per
2.5. Ethical considerations day, and most worked 50e60 hours per week on an average (39.9%),
followed by 42e49 hours (31.5%) and 32e40 hours (28.5%) (Table 1).
Data collection proceeded on obtaining approval from the
Institutional Review Board at Wonju College of Medicine, Yonsei 3.2. Correlations between emotional labor and turnover intention
University (IRB NO: YWNR-15-2-024). Before the commencement
of data collection, we explained the purpose of the study to the Turnover intention was positively correlated with the following
chief executive nurse at each hospital and sought their cooperation. factors of emotional labor: overload and conflicts in customer ser-
Subsequently, we provided written explanations on the study vice (r ¼ 0.160, p ¼ 0.000), emotional disharmony and hurt
purpose to participants and obtained signed informed consent (r ¼ 0.266, p ¼ 0.000), organizational surveillance and monitoring
forms from them. The informed consent forms included informa- (r ¼ 0.196, p ¼ 0.000), and lack of a supportive and protective
tion on the purpose of the study, assurance of anonymity, confi- system in the organization (r ¼ 0.190, p ¼ 0.000). Thus, Hypothesis
dentiality agreement, and withdrawal of participation, and we 1 was supported (Table 2).
explained that the collected data would only be used for study
purposes. Participants returned the completed questionnaires in an 3.3. The mediating role of burnout in the relationship between
envelope addressed to the researcher. As an incentive to partici- emotional labor and turnover intention
pate, all nurses who completed the survey were given gift cards of
an estimated worth of 15000 won (approx. 13.22 USD). All data The results of the mediation analyses conducted to test
were collected between November 1 and November 30, 2015. Hypothesis 2 were as follows. “Emotional demand and regulation”
 C.-Y. Back et al / Mediating Effects of Burnout 91

Table 2
Correlations between emotional labor factors and turnover intention (n ¼ 606)

Variables 1 2 3 4 5 6 7
1. Emotional demand and regulation 1
2. Overload and conflicts in customer service 0.378 (0.000) 1
3. Emotional disharmony and hurt 0.499 (0.000) 0.634 (0.000) 1
4. Organizational surveillance and monitoring 0.249 (0.000) 0.398 (0.000) 0.503 (0.000) 1
5. Lack of a supportive and protective 0.109 (0.007) 0.064 (0.118) 0.150 (0.000) 0.064 (0.114) 1
system in the organization
6. Burnout 0.323 (0.000) 0.412 (0.000) 0.548 (0.000) 0.298 (0.000) 0.198 (0.000) 1
7. Turnover intention 0.004 (0.922) 0.160 (0.000) 0.266 (0.000) 0.196 (0.000) 0.190 (0.000) 0.317 (0.000) 1
All values are Pearson's correlation coefficients (p-value).

did not predict turnover intention in the first step (corresponding 4. Discussion
to Model 2 explained earlier; b ¼ 0.048, p ¼ 0.209). However, it did
predict burnout in the second step (corresponding to Model 1; In this study, we examined the mediating effect of burnout on
b ¼ 0.35, p ¼ 0.000), and both of these were significantly associated the relationship between emotional labor and turnover intention.
with turnover intention in the third step (corresponding to Model The findings indicated that overload and conflict in customer ser-
3, b ¼ -0.046, p ¼ 0.244; b ¼ 0.265, p ¼ 0.000). However, as these vice, emotional disharmony and hurt, organizational surveillance
results did not meet Baron and Kenny’s criteria, we could not and monitoring, and lack of a supportive and protective system in
conclude that burnout mediated the relationship of emotional de- the organization were significantly associated with burnout and
mand and regulation with turnover intention (Table 3). turnover intention. This coincides with the results of prior studies
For “overload and conflicts in customer service,” all three steps that reported that emotional labor induces burnout, and that it is
yielded significant relationships. Specifically, it significantly pre- positively correlated with turnover intention [21,26,27]. However,
dicted turnover intention (first step; b ¼ 0.14, p ¼ 0.000) and notably, emotional demand and regulation was not associated with
burnout (second step; b ¼ 0.41, p ¼ 0.000), and both overload and turnover intention. There is, unfortunately, a lack of evidence to
conflicts in customer service and burnout significantly predicted support this result. Although emotional demand and regulation
turnover intention (third step; b ¼ 0.044, p ¼ 0.269; b ¼ 0.230, were associated with burnout, most participants might consider
p ¼ 0.000). Given the notable reduction in standardized beta co- this factor a natural part of their role as a nurse. Hence, this factor
efficients between the first and third steps, standardized beta co- may not lead to turnover intention.
efficient of overload and conflicts in customer service is not In the present study, overload and conflict in customer service,
significant. Therefore, the results of a Sobel test indicated that emotional disharmony and hurt, emotional disharmony and hurt
burnout have a significant full mediating effect on the relationship (i.e., emotional dissonance), organizational surveillance and
between overload and conflicts in customer service and turnover monitoring, and lack of a supportive and protective system in the
intention (z ¼ 5.05, p ¼ 0.000; Fig. 1).(Tables 4, 5, 6, 7) organization were the significant predictors of burnout and turn-
For “emotional disharmony and hurt,” we again found signifi- over intention. Emotional dissonance is defined as the conflict be-
cant effects for all three steps (first step: b ¼ 0.24, p ¼ 0.000; second tween positive emotional displaydnamely, the emotions required
step: b ¼ 0.54, p ¼ 0.000; third step: b ¼ 0.14, p ¼ 0.001; b ¼ 0.17, by the organizationdand individuals’ felt emotions [28]. Previous
p ¼ 0.000). Here, the decreased standardized beta coefficients be- studies have demonstrated a clear and consistent relationship be-
tween the first and third steps indicated a partial mediating effect tween emotional dissonance and burnout among professionals in
of burnout on the relationship of emotional disharmony and hurt the human service industry [29,30]. In other words, these studies
with turnover intention. This mediating effect was verified by sig- have stressed that suppressing one’s internal emotions is detri-
nificant Sobel test results (z ¼ 3.73, p ¼ 0.000; Fig. 2). mental to the health and well-being of organization members.
Partial mediating effects were also found for two other factors of We found that burnout partially mediated the effects of three of
emotional labor: “organizational surveillance and monitoring” and the five factors of emotional labor: emotional disharmony and hurt,
“lack of a supportive and protective system in the organization.” For organizational surveillance and monitoring, and lack of a sup-
“organizational surveillance and monitoring,” all three steps portive and protective system in the organization. This finding
showed significant beta coefficients (first step: b ¼ 0.18, p ¼ 0.000; coincides with the emotional dissonance theory [17], and it is
second step: b ¼ 0.30, p ¼ 0.000; third step: b ¼ 0.12, p ¼ 0.002; supported by other studies indicating that emotional exhaustion
b ¼ 0.21, p ¼ 0.000), and the decrease in coefficients between the maybe an important predictor of turnover intention. In particular,
first and third step, combined with a significant Sobel test result conflicts between displayed and actual emotion can exhaust
(z ¼ 4.63, p ¼ 0.000) indicated that burnout had a mediating effect workers emotionally, which in turn may motivate withdrawal be-
on the relationship of organizational surveillance and monitoring haviors such as turnover intention [20]. Furthermore, Lindquist and
with turnover intention (Fig. 3). Whitehead [31] noted that emotional labor and turnover intention
For “lack of a supportive and protective system in the organi- are not involved in a direct causal relationship; rather, emotional
zation,” all three steps yielded significant beta coefficients (first labor induces job stress, which in turn influences organizational
step: b ¼ 0.18, p ¼ 0.000; second step: b ¼ 0.20, p ¼ 0.000; third effectiveness, including factors such as job satisfaction or turnover
step: b ¼ 0.14, p ¼ 0.000: b ¼ 0.22, p ¼ 0.000), and the decrease in intention.
these coefficients between the first and third steps, coupled with Turnover intention refers to a worker’s intention to leave his or
the significant Sobel test (z ¼ 3.93, p ¼ 0.000), again confirmed the her current workplace, or prudent and considerate thoughts about
mediating effect of burnout (Fig. 4). leaving the organization [32]. It is recognized as the final step in the
The results fully and partially support the mediating role of process of turnover [33,34]. Although personal factors have been
burnout in the relationship between the subfactors of emotional found to influence turnover per se, organizational factors, such as
labor and turnover intention. Thus, Hypothesis 2 was partially organizational stress and leadership, have a considerable influence
supported. on turnover intention [35]. For instance, Flinkman et al. [36]
92 Saf Health Work 2020;11:88e96

<0.001
<0.001
0.027

0.006
<0.001
0.244
<0.001
p
Burnout -> turnover

-0.086
-0.221
-0.145

-0.046
0.106
0.149

0.265
b
Model 3

9.364 (1.567)

0.113 (0.028)
-0.719 (0.325)
-2.468 (0.447)
-6.408 (1.625)
1.128 (0.405)

-0.012 (0.010)
0.306 (0.046)
B(SE)

0.213
24.343
<0.001
0.006
<0.001
<0.001
0.001
<0.001
0.209
Emotional demand and regulation -> turnover

Fig. 1. Mediating effects of burnout on the relationship of overload and conflicts in

p

customer service with turnover intention.

reported that the following factors influence turnover intention

0.137
0.164
0.048
-0.111
-0.257
-0.172

among hospital nurses: young age, male, high level of education,

b
Model 2

low wage, low job commitment, low emotional commitment, low

job satisfaction, weak support system, low job autonomy, burnout,
and job-related conflict with family members. Similar results have
been found in the Korean literature as well. For instance, Kim and
11.712 (1.583)
-0.927 (0.335)
-2.876 (0.459)
-7.591 (1.674)
1.458 (0.417)
0.124 (0.029)
0.013 (0.010)

Kim [37] found that turnover intention was negatively correlated

B(SE)

with job satisfaction, organizational commitment, and job mar-

0.155
19.460
<0.001

keting although it was positively associated with job stress and

burnout.
Mediating effects of burnout on the relationship between emotional demand and regulation and turnover intention (n ¼ 606)

We found that overload and conflicts in customer service, as a

subfactor of emotional labor, had a direct effect on turnover
intention, and this relationship was fully mediated by burnout. As
0.020
0.001
0.008
0.003
0.128
<0.001
Emotional demand and regulation -> burnout

per the job demands-resources model, high job demandsdsuch

p

as overload and conflicts with patientsdand few job resources are

associated with poorer organizational commitment, which, in
turn, relates to turnover intention [38]. However, more evidence
on this result is needed. We suggest that future research should
0.117
0.058
0.352
-0.094
-0.138
-0.101

take a closer look at this factor of emotional labor.

b
Model 1

Studying nurses’ turnover intention maybe more cost effective

for hospitals than merely studying turnover behavior of all hos-
pital employees. In addition, identifying the key factors related to
turnover intention enables administrators to develop in-
7.664 (1.368)
-0.678 (0.290)
-1.331 (0.396)
-3.862 (1.446)
1.076 (0.360)
0.038 (0.025)
0.081 (0.009)

terventions to prevent nurses’ turnover [39]. Because nurses ac-

B(SE)

count for a critical proportion of personnel in medical facilities,

0.154
19.317
<0.001

understanding the factors related to turnover intention among

them is becoming an increasingly important and reasonable
aspect of hospital management strategy [40]. Burnout manifests
differently based on the job types, although it appears to be much
Emotional demand and regulation

more prevalent in service employees than in manufacturing

workers [41].
Taken together, these findings indicate that it is needed to pay
attention to burnout among nurses, given their high levels of
emotional labor. Indeed, it is especially important given that the
impacts of burnout go beyond individual members; namely, it is
Working hours
Age (30 vs 20)
Age (40 vs 20)
Age (50 vs 20)

not beneficial to the organizational goals (e. g. productivity and

Shift work

organizational efficiency), increases turnover, reduces positive job

Variable

Burnout

attitudes, and decreases work productivity [42]. All of these ulti-

mately cause negative effects among nursing professions and
patients [43].
Independent variable

This study has some limitations. First, selection bias is a po-

tential limitation of this study because we selected the partici-
Control variables

pating facilities without randomization and participants could

Adjusted R2

choose whether to participate in the study. Furthermore, all data

(Constant)

Parameter

in this study were obtained through a self-administered ques-

Table 3

tionnaire, thus presenting the possibility of common method bias.

p
F

It cannot exclude the possibilities to select out from enrollment of

Table 4
Mediating effects of burnout on the relationship between overload and conflicts in customer service and turnover intention (n ¼ 606)

Variable Model 1 Model 2 Model 3

Overload and conflicts in customer service -> burnout Overload and conflicts in customer service -> turnover Burnout -> turnover

B(SE) b p B(SE) b p B(SE) b p

(Constant) 10.594 (1.195) 11.371 (1.406) 8.553 (1.458)
Control variables Age (30 vs 20) -0.568 (0.281) -0.079 0.044 -0.949 (0.331) -0.114 0.004 -0.798 (0.323) -0.096 0.014
Age (40 vs 20) -1.017 (0.384) -0.105 0.008 -2.842 (0.452) -0.254 <0.001 -2.571 (0.443) -0.230 <0.001
Age (50 vs 20) -3.645 (1.408) -0.096 0.010 -7.401 (1.658) -0.167 <0.001 -6.432 (1.625) -0.146 <0.001
Shift work 0.855 (0.350) 0.093 0.015 1.426 (0.412) 0.134 0.001 1.199 (0.403) 0.113 0.003
Working hours 0.008 (0.024) 0.012 0.755 0.112 (0.029) 0.148 <0.001 0.110 (0.028) 0.146 <0.001
Independent variable Overload and conflicts in customer service 0.067 (0.006) 0.409 <0.001 0.026 (0.007) 0.138 <0.001 0.008 (0.008) 0.044 0.269
Parameter Burnout 0.266 (0.047) 0.230 <0.001
Adjusted R2 0.198 0.171 0.212
F 25.825 21.867 24.319

C.-Y. Back et al / Mediating Effects of Burnout

p <0.001 <0.001 <0.001

Table 5
Mediating effects of burnout on the relationship between emotional disharmony and hurt and turnover intention (n ¼ 606)

Variable Model 1 Model 2 Model 3

Emotional disharmony and hurt -> burnout Emotional disharmony and hurt -> turnover Burnout -> turnover

B(SE) b p B(SE) b p B(SE) b p

(Constant) 10.400 (1.087) 10.888 (1.359) 8.856 (1.442)
Control variables Age(30 vs 20) -0.549 (0.258) -0.76 0.034 -0.958 (0.323) -0.115 0.003 -0.851 (0.321) -0.102 0.008
Age(40 vs 20) -1.091 (0.354) -0.113 0.002 -2.887 (0.442) -0.258 <0.001 -2.674 (0.440) -0.239 <0.001
Age(50 vs 20) -3.237 (1.297) -0.085 0.013 -7.120 (1.622) -0.161 <0.001 -6.487 (1.612) -0.147 <0.001
Shift work 0.541 (0.323) 0.059 0.094 1.269 (0.403) 0.119 0.002 1.163 (0.400) 0.109 0.004
Working hours 0.003 (0.022) 0.005 0.890 0.107 (0.028) 0.141 <0.001 0.106 (0.028) 0.140 <0.001
Independent variable Emotional disharmony and hurt 0.086 (0.005) 0.539 <0.001 0.043 (0.007) 0.235 <0.001 0.026 (0.008) 0.144 0.001
Parameter Burnout 0.195 (0.051) 0.169 <0.001
Adjusted R2 0.320 0.207 0.225
F 48.434 27.364 26.140
P <0.001 <0.001 <0.001
Sobel test Z ¼ 3.73, p¼<0.001.

93
 94
Table 6
Mediating effects of burnout on the relationship between organizational surveillance and monitoring and turnover intention (n ¼ 606)

Variable Model 1 Model 2 Model 3

Organizational surveillance and monitoring -> burnout Organizational surveillance and monitoring -> turnover Burnout -> turnover

B(SE) b p B(SE) b p B(SE) b p

(Constant) 12.519 (1.224) 11.662 (1.364) 8.590 (1.443)
Control variables Age(30 vs 20) -0.578 (0.294) -0.080 0.050 -1.007 (0.328) -0.121 0.002 -0.866 (0.321) -0.104 0.007
Age(40 vs 20) -0.933 (0.402) -0.097 0.021 -2.804 (0.448) -0.251 <0.001 -2.575 (0.439) -0.230 <0.001
Age(50 vs 20) -4.260 (1.473) -0.112 0.004 -7.626 (1.642) -0.173 <0.001 -6.581 (1.614) -0.149 <0.001
Shift work 0.899 (0.366) 0.098 0.014 1.461 (0.408) 0.137 <0.001 1.241 (0.401) 0.117 0.002
Working hours 0.018 (0.025) 0.028 0.469 0.110 (0.028) 0.182 <0.001 0.106 (0.028) 0.140 <0.001
Independent variable Organizational surveillance and monitoring 0.050 (0.006) 0.299 <0.001 0.035 (0.007) 0.182 <0.001 0.023 (0.007) 0.118 0.002
Parameter Burnout 0.245 (0.044) 0.212 <0.001
Adjusted R2 0.120 0.185 0.224
F 14.800 23.940 25.883
p <0.001 <0.001 <0.001

Sobel test Z ¼ 4.63, p¼<0.001.

Saf Health Work 2020;11:88e96

Table 7
Mediating effects of burnout on the relationship between lack of a supportive and protective system in the organization and turnover intention (n ¼ 606)

Variable Model 1 Model 2 Model 3

Lack of a supportive and protective Lack of a supportive and protective Burnout -> turnover
system in the organization -> burnout system in the organization -> turnover

B(SE) b p B(SE) b p B(SE) b p

(Constant) 12.314 (1.288) 10.909 (1.396) 7.768 (1.458)
Control variables Age(30 vs 20) -0.496 (0.302) -0.069 0.101 -0.984 (0.328) -0.118 0.003 -0.857 (0.320) -0.103 0.008
Age(40 vs 20) -0.929 (0.413) -0.096 0.025 -2.792 (0.448) -0.250 <0.001 -2.555 (0.438) -0.228 <0.001
Age(50 vs 20) -4.213 (0.151) -0.110 0.006 -7.558 (1.642) -0.171 <0.001 -6.484 (1.608) -0.147 <0.001
Shift work 0.863 (0.377) 0.094 0.022 1.443 (0.408) 0.136 <0.001 1.223 (0.399) 0.115 0.002
Working hours 0.032 (0.026) 0.049 0.217 0.118 (0.028) 0.156 <0.001 0.110 (0.027) 0.145 <0.001
Independent variable Lack of a supportive and 0.042 (0.008) 0.197 <0.001 0.045 (0.009) 0.181 <0.001 0.034 (0.009) 0.138 <0.001
protective system in the
organization
Parameter Burnout 0.255 (0.043) 0.220 <0.001
Adjusted R2 0.070 0.185 0.229
F 8.635 23.943 26.693
p <0.001 <0.001 <0.001
Sobel test Z ¼ 3.93, p¼<0.001.
 C.-Y. Back et al / Mediating Effects of Burnout 95

between emotional labor and turnover intention in clinical nurses,

in an attempt to devise intervention strategies to reduce nurses’
turnover intention and to ultimately improve the management of
nursing personnel and quality of medical services. The increasing
attention on the concept of emotional labor allowed us to use an
emotional labor scale that was developed considering Korea’s so-
ciocultural characteristics and to verify its validity in the field of
nursing.

Conflicts of interest

The authors declared no conflicts of interests.

Acknowledgments
Fig. 2. Mediating effects of burnout on the relationship of emotional disharmony and
hurt with turnover intention.
The authors would like to thank Mr. Myung-Ha Kim for his
useful contribution of EndNote of this article.

Appendix A. Supplementary data

Supplementary data to this article can be found online at

https://doi.org/10.1016/j.shaw.2020.01.002.

References

[1] Brilowski GA, Cecilia Wendler M. An evolutionary concept analysis of caring.

J Adv Nurs 2005;50:641e50.
[2] Schaubroeck J, Jones JR. Antecedents of workplace emotional labor di-
mensions and moderators of their effects on physical symptoms. J Organ
Behav 2000;21:163e83.
[3] Hochshild AR. The managed heart. Berkeley (CA): University of California;
1983.
[4] World Health Organization. New global alliance seeks to address worldwide
Fig. 3. Mediating effects of burnout on the relationship of organizational surveillance shortage of doctors, nurses and other health workers [Internet]. Geneva:
and monitoring with turnover intention. World Health Organization. 2006 [cited 2016 Nov 10]. Available from: http://
www.who.int/mediacentre/news/releases/2006/pr26/en/.
[5] Bureau of Labor Statistics. Occupation outlook handbook [Internet]; 2004
[cited 2016 Nov 10]. Available from: https://www.bls.gov/ooh/.
[6] Nixon AE, Yang LQ, Spector PE, Zhang X. Emotional labor in China: do
perceived organizational support and gender moderate the process? Stress
Health 2011;27:289e305.
[7] Cavanagh SJ, Coffin DA. Staff turnover among hospital nurses. J Adv Nurs
1992;17:1369e76.
[8] Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol 2001;52:
397e422.
[9] Cordes CL, Dougherty TW. A review and an integration of research on job
burnout. Acad Manage Rev 1993;18:621e56.
[10] Chang SJ, Kang HT, Kim SY, Kim IA, Kim JI, Kim HY, Kim HS, Kim WC, Park SG,
Song HS, Oh SS, Yoon JH, Lee YJ, Lee JH, Lee CG, Chung JJ, Choi EH, Tak JK. The
development of Korean emotional labor scale and Korean violence scale 2013.
Seoul (Korea): The Korea Occupational Safety and Health Agency; 2014.
[11] Maslach C, Jackson SE. Maslach burnout inventory. Palo Alto (CA): Consulting
Psychlogists Press; 1981.
[12] Kim YS. Nurses job stress influencing on the burnout and turnover intentions.
Unpublished master’s thesis. Seoul, Korea: Kyung Hee University; 2011.
Fig. 4. Mediating effects of burnout on the relationship of lack of a supportive and [13] Chan ZC, Tam WS, Lung MK, Wong WY, Chau CW. A systematic literature
protective system in the organization with turnover intention. review of nurse shortage and the intention to leave. J Nurs Manag 2013;21:
605e13.
[14] Jourdain G, Chênevert D. Job demandseresources, burnout and intention to
leave the nursing profession: a questionnaire survey. Int J Nurs Stud 2010;47:
the study so-called “healthy worker effect”. This should be taken 709e22.
[15] Grandey AA. Emotional regulation in the workplace: a new way to concep-
into consideration when interpreting the present results. Second, tualize emotional labor. J Occup Health Psychol 2000;5:95e110.
we could not include the occupational factors such as bullying or [16] Huynh T, Alderson M, Thompson M. Emotional labour underlying caring: an
workplace violence from clients or supervisor. It is needed to evolutionary concept analysis. J Adv Nurs 2008;64:195e208.
[17] Bartram T, Casimir G, Djurkovic N, Leggat SG, Stanton P. Do perceived high
examine some eligible occupational risks in the future study. performance work systems influence the relationship between emotional
Despite these limitations of this study, our results are note- labour, burnout and intention to leave? A study of Australian nurses. J Adv
worthy with reference to the implication that the different factors Nurs 2012;68:1567e78.
[18] Leiter MP, Maslach C. Nurse turnover: the mediating role of burnout. J Nurs
of emotional labor may have differential effects on mediators and
Manag 2009;17:331e9.
outcomes. Besides the effects obtained previously, it is possible that [19] Zapf D. Emotion work and psychological well-being: a review of the literature
these factors have independent contributions to various other and some conceptual considerations. Hum Resour Manag Rev 2002;12:237e
outcomes. 68.
[20] Hartel CEJ, Hsu C, Boyle MV. A conceptual examination of the causal se-
In conclusion, this study suggests that emotional labor is related quences of emotional labour, emotional dissonance and emotional exhaus-
to turnover intention and burnout mediates the relationship tion: the argument for the role of contextual and provider characteristics. In:
96 Saf Health Work 2020;11:88e96

Ashkanasy NM, Hartel CEJ, Zerbe WJ, editors. Managing emotions in work- [33] Bluedorn AC. The theories of turnover: causes, effects, and meaning. Res Sociol
place. New York (NY): ME Sharpe; 2000. p. 251e75. Organ 1982;1:75e128.
[21] Lee RT, Ashforth BE. A meta-analytic examination of the correlates of the three [34] Tett RP, Meyer JP. Job satisfaction, organizational commitment, turnover
dimensions of job burnout. J Appl Psychol 1996;81:123e33. intention, and turnover: path analyses based on meta-analytic findings. Pers
[22] Wright TA, Cropanzano R. Emotional exhaustion as a predictor of job per- Psychol 1993;46:259e93.
formance and voluntary turnover. J Appl Psychol 1998;83:486e93. [35] Coomber B, Barriball KL. Impact of job satisfaction components on intent to
[23] Morris JA, Feldman DC. The dimensions, antecedents, and consequences of leave and turnover for hospital-based nurses: a review of the research liter-
emotional labor. Acad Manage Rev 1996;21:986e1010. ature. Int J Nurs Stud 2007;44:297e314.
[24] Baron RM, Kenny DA. The moderatoremediator variable distinction in social [36] Flinkman M, Leino-Kilpi H, Salanterä S. Nurses’ intention to leave the pro-
psychological research: conceptual, strategic, and statistical considerations. fession: integrative review. J Adv Nurs 2010;66:1422e34.
J Pers Soc Psychol 1986;51:1173e82. [37] Kim JK, Kim MJ. A review of research on hospital nurses’ turnover intention.
[25] Krause MR, Serlin RC, Ward SE, Rony RYZ, Ezenwa MO, Naab F. Testing J Korean Acad Nurs Adm 2011;17:538e50.
mediation in nursing research: beyond Baron and Kenny. Nurs Res 2010;59: [38] Bakker A, Demerouti E, Schaufeli W. Dual processes at work in a call centre: an
288e94. application of the job demandseresources model. Eur J Work Organ Psychol
[26] Brotheridge CM, Grandey AA. Emotional labor and burnout: comparing two 2003;12:393e417.
perspectives of “people work”. J Vocat Behav 2002;60:17e39. [39] Moon SJ, Han SS. A predictive model on turnover intention of nurses in Korea.
[27] Zhang Q, Zhu W. Exploring emotion in teaching: emotional labor, burnout, J Korean Acad Nurs 2011;41:633e41.
and satisfaction in Chinese higher education. Commun Educ 2008;57:105e22. [40] Jeong JH, Kim KH, Kim JS. The risk factors influencing turnover intention of
[28] Rafaeli A, Sutton RI. The expression of emotion in organizational life. Res nurses. J Korean Acad Nurs Adm 2008;14:35e44.
Organ Behav 1989;11:1e42. [41] Sears Jr SF, Urizar Jr GG, Evans GD. Examining a stress-coping model of
[29] Heuven E, Bakker A. Emotional dissonance and burnout among cabin atten- burnout and depression in extension agents. J Occup Health Psychol 2000;5:
dants. Eur J Work Organ Psychol 2003;12:81e100. 56e62.
[30] Zapf D, Seifert C, Schmutte B, Mertini H, Holz M. Emotion work and job [42] Cameron SJ, Horsburgh ME, Armstrong-Stassen M. Job satisfaction, propensity
stressors and their effects on burnout. Psychol Health 2001;16:527e45. to leave and burnout in RNs and RNAs: a multivariate perspective. Can J Nurs
[31] Lindquist CA, Whitehead JT. Burnout, job stress and job satisfaction among Adm 1994;7:43e64.
southern correctional officers: perceptions and causal factors. J Offender [43] Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing
Couns Serv Rehabil 1986;10:5e26. and patient mortality, nurse burnout, and job dissatisfaction. JAMA 2002;288:
[32] Mobley WH, Horner SO, Hollingsworth AT. An evaluation of precursors of 1987e93.
hospital employee turnover. J Appl Psychol 1978;63:408e14.