Effect of an Empowerment-Based Psychoeducation Program on Burnout and Psychological Outcomes in Nurse Managers

1. Introduction

Today's healthcare systems are undergoing a profound transformation driven by increasing demand for services, rapidly advancing technological innovations, and increasingly complex organizational structures. At the center of these complex structures are nurse managers, who serve as a vital link between senior leadership, interdisciplinary teams, and frontline healthcare workers.

Nurse leaders are responsible for making daily decisions that directly impact patient safety and the quality of care; they hold a strategic position in the effective management of healthcare teams and simultaneously serve as agents of change in the implementation of organizational goals.However, this role is becoming increasingly challenging due to growing psychological demands, heavy workloads, and constant pressure from resource constraints. In addition, nurse managers must navigate quality indicators and financial responsibilities within the healthcare organization while simultaneously addressing staff emotional needs, managing team conflicts, and serving as a bridge between senior management and the clinical floor. This multi-layered role structure places nurse managers at risk for burnout, stress, and intention to leave.

Indeed, it has been demonstrated that burnout and work-life balance issues are prevalent among nurse leaders and that these factors increase the likelihood of organizational turnover.

Burnout a psychological syndrome resulting from deteriorating interpersonal relationships in the workplace and chronic occupational stress is particularly prevalent among healthcare personnel, especially nurses. Nurses are particularly susceptible to burnout due to predisposing factors such as being female, working rotating shifts, serving in particularly demanding work settings (such as intensive care and oncology), having limited experience, and working in a high-risk environment. The prevalence of this syndrome has increased alongside the COVID-19 pandemic, reaching 49% in the United States and 79% in the United Kingdom.

The consequences of burnout among nurses include: deterioration in patient care and quality, negative effects on nurses' mental and physical health (such as depression, insomnia, and irritability), and organizational issues like increased absenteeism due to sick leave. Burnout among nurse managers is not merely an individual problem but also an organizational risk factor that directly impacts care quality and patient safety. Recent meta-analyses have demonstrated that nurse burnout is significantly associated with patient safety, quality of care, and patient satisfaction. Additionally, it has been shown that leadership styles play a decisive role in determining nurses' levels of burnout, job commitment, and performance; supportive and empowering leadership has been associated with more positive outcomes.

To manage these challenges related to burnout, empowerment emerges as both a key managerial strategy and one of the fundamental determinants of individual well-being and organizational effectiveness. Interventions aimed at enhancing the individual and managerial capacity of nurse managers hold strategic importance for the sustainability and resilience of healthcare institutions. Empowerment is a process that involves not only increasing an employee's self-efficacy to ensure competence but also identifying and eliminating the conditions that cause weakness. Psychological empowerment, grounded in self-efficacy theory, is defined as an internal motivational state emerging across four cognitive dimensions: meaning (alignment of work goals with personal values), competence (confidence in one's abilities), autonomy (independence in initiating and sustaining work), and influence (belief in the ability to impact organizational outcomes). The organizational benefits of a psychologically empowered nursing workforce are strongly supported by the literature. Research shows that nurses with high levels of empowerment experience increased job satisfaction, strengthened organizational commitment, and enhanced innovative behavior. It is also noted that psychological mpowerment functions as a protective mechanism against negative conditions such as burnout, emotional exhaustion, and workplace bullying.

A key point particularly emphasized in the literature is the phenomenon defined as the cascade effect: For a leader to empower others, they must first be empowered themselves. It is noted that nurse managers with a high perception of psychological empowerment provide a more supportive work environment for their staff , resulting in improved patient outcomes and reduced turnover intentions. It is stated that psychological empowerment in nurse managers has a significant impact on job satisfaction, performance, and the overall work environment. Empirical evidence suggests that the communication behaviors of nurse managers strengthen the relationship between psychological empowerment and job performance.Systematic reviews indicate strong negative correlations between psychological empowerment and burnout. Studies conducted in Turkey similarly reveal that empowerment is associated with job satisfaction and performance among nurses.However, research indicates that nurses do not feel sufficiently empowered.

The concepts of self-leadership and psychological resilience also emerge as two complementary core psychological resources that enable nurse managers, in particular, to meet the complex and multidimensional expectations of their roles. Self-leadership is defined as an individual's natural ability to influence, manage, control, and push oneself toward desired goals. This indicates that it is not sufficient for nurse managers to merely fulfill their managerial roles; they must also effectively manage their own psychological resources. Research indicates that self-leadership is positively associated with job satisfaction, performance, and professional commitment among nurses. Therefore, developing self-leadership skills may contribute to nurse managers' ability to manage complex role demands more effectively.

Resiliece is a developable capacity that enables individuals to cope with stress and uncertainty. It manifests itself in forms such as optimism, humor, and self- efficacy. Nurses' work involves close interaction with people, illness, and suffering, and for them, resilience is a critically important quality that mitigates the negative effects of workplace stressors and makes burnout less likely. The literature emphasizes that resilience serves as a protective factor that reduces burnout and enhances psychological well-being among nurses. For Systematic nurse managers, resilience is not merely a matter of individual well-being; it is also a critical competency regarding the effectiveness of crisis management, team leadership, and decision- making processes.

Consequently, self-leadership skills enable individuals to regulate their own behavior and maintain internal control in stressful situations, while psychological resilience provides the capacity to adapt to these stressors and mitigate their negative effects. Indeed, the literature indicates that individuals with high levels of self-leadership and resilience cope more effectively with stress and exhibit lower levels of burnout. Nurse managers play a critical role in both preventing burnout and demonstrating more sustainable and effective leadership in team management by enhancing resilience. Therefore, addressing both self-leadership and resilience components in interventions designed for nurse managers is considered a robust approach from both theoretical and practical perspectives.

Mindfulness has been studied for many years in the field of clinical psychology and in relation to various disorders, and numerous positive effects have been identified. In recent years, interest in mindfulness has also grown in the literature on management and organizational behavior. Simply put, mindfulness is non- judgmental awareness and acceptance of the present moment or current circumstances. Mindfulness-based interventions encourage self-observation and appreciation, enabling individuals to reframe their perceptions and understanding of events in a non-judgmental manner.

At this point, a structured training program aimed at empowering nurse managers emerges as a critical need. This is because nurse managers often transition into this role based on clinical experience; however, they have limited access to training opportunities that systematically develop critical skills such as stress management, self-leadership, psychological resilience, and resilience. However, interventions aimed at developing resilience and coping skills have been shown to increase nurses' job satisfaction and psychological well-being while reducing burnout. In particular, it has been demonstrated that mindfulness practices reduce stress and burnout among healthcare workers while enhancing psychological well-being and resilience.

However, despite the critical role of nurse managers in healthcare systems, there is a limited body of research on psycho-educational interventions targeting nurse managers. In particular, the lack of experimental studies that holistically address burnout, self-leadership, psychological empowerment, and resilience is notable. Studies conducted in Turkey have focused on the relationship between burnout and job satisfaction among nurses, and intervention-based research targeting nurse managers remains limited. The development and evaluation of an empowerment-based psycho-educational program for nurse managers holds the potential to support not only individual well-being but also team performance, quality of care, and organizational sustainability.

This project is designed as a randomized controlled trial to evaluate the effects of a psycho-educational empowerment program for nurse managers on burnout, self-leadership, psychological empowerment, and psychological resilience. 2. Method 2.1. Research Design This study is designed as a randomized controlled trial with pre-test, post-test, and follow-up (3-month) assessments.

2.2. Participants Inclusion criteria for participants are: being 18 years of age or older; being a full-time nurse; being able to speak, read, and understand Turkish well; being able to provide informed consent; and being willing to comply with all study procedures and requirements throughout the duration of the study. Exclusion criteria include: not holding a full-time nursing position; having a major mental illness and currently receiving medication or psychotherapy for that illness; having an active illness (such as a malignancy) or being in the grieving process that prevents participation in the program; and being in a role that conducts annual evaluations of head nurses or not being a head nurse.

The selection and enrollment of nurse managers for the study will be conducted in accordance with the hospital's institutional policy. Details regarding the study will be shared and information provided during unit head meetings to facilitate participation in the study.

2.3.Population and Sample The study population will consist of 65 clinical/unit head nurses working at Süleyman Demirel University Research and Application Hospital. Since the variables of burnout, self- leadership, psychological empowerment, and psychological resilience can be influenced by organizational characteristics such as the functioning of nursing services and organizational culture within the hospital, a single central research population has been selected. The sample will consist of clinical head/manager nurses in the intervention and control groups, selected through randomization based on inclusion and exclusion criteria. Nurses in the control group will be enrolled in the psycho-educational program after the intervention group has completed the program and data collection has been finalized.

Firs

• Change in self-leadership levels measured using the Self-Leadership Scale. [Срок оценки: Time Frame: Baseline (T1), 5 weeks after intervention (T2), and 3-month follow-up (T3).]
• Change in psychological empowerment levels measured using the Psychological Empowerment Scale. [Срок оценки: Time Frame: Baseline (T1), 5 weeks after intervention (T2), and 3-month follow-up (T3).]
• Change in resilience levels measured using the Brief Resilience Scale [Срок оценки: Baseline (T1), 5 weeks after intervention (T2), and 3 months after intervention (T3)]