Mediating Effect of Employee Performance on the Relationship Between Emotional Labour and Intent to Leave Among Nurses

Abstract

In this study, it was aimed to examine the effect of nurses’ emotional labor levels on their intention to leave and to determine whether employee performance plays a mediating role in this relationship. The study is of descriptive cross-sectional type, which was conducted through a questionnaire on nurses. The surface acting has positive effect on the intent to leave among nurses, whereas deep acting has negative effect; employee performance has partial mediating role on the relationship between the surface acting and intent to leave, and the relationship between deep acting and intent to leave. The study is considered to provide significant tips in the identification of nurses with higher risk to leave the work, and in deciding managerial interventions that would be realised against such circumstances. It is suggested that it may be beneficial for nurse managers to organise training in their units, to evaluate the performance of nurses at regular intervals and thus to determine the reason for the increase and decrease, to plan activities that will reduce emotional burden.

Keywords

Deep acting emotional labour employee performance intent to leave nursing surface acting Turkey

Introduction

The concept of emotional labour has been first introduced by Hochschild (1983) as ‘the effort of employees towards showing the feelings expected from them as a requirement of their work’ (Hennig-Thurau et al., 2006). The employees show their expected emotions in two different ways as surface acting and deep acting (Grandey, 2003). The surface-acting employees act in the way as if they feel the emotions because of the professional or institutional requirement; the deep-acting employees focus on the internal feelings and try to really feel and show that emotion like an actor (Steinberg & Figart, 1999). Therefore, in terms of surface acting, the employees do not internalise the emotion, which is often realised by the people provided with the services, yet with regard to the deep acting, the employees satisfy the people provided with the services as they feel the emotion themselves and perform a good acting (Grandey et al., 2005).

It is a known fact that the concept of emotional labour is more significant for nurses since their relationship with the patients and their relatives are relatively more intense than the other healthcare professional (Bartram et al., 2012). Nurses are generally expected to be nice, show empathy towards their patients, feel their problems and engage an emotional labour that would not reveal their negative emotions (Chou et al., 2012; Mitchell & Smith, 2003). However, such intense management of emotions causes a self-withdrawal from work over time and finally leave the work (Chau et al., 2009).

Particularly the recruitment of nurses and prevention of their leave from work are still a crucial problem around the world (Cheng et al., 2013; Coomber & Barriball, 2007; De Gieter et al., 2011; Flinkman et al., 2008; Liang et al., 2016). Although the rates of leaving work among nurses vary between 15.1% and 44.3% among countries (Duffield et al., 2014), it is known that the aging of population and increase in chronic diseases bring more demand towards the nursing services (Takase, 2010). Hence, a high level of leaving work among nurses would cause the lack of quality in the provision of required services due to the workload (Hayes et al., 2006; Mazurenko et al., 2015), problems with regard to the service sustainability (Blegen et al., 2017) and negative impacts on the institutional capacity and financial situation (Rivers et al., 2005; Roche et al., 2015).

The behaviour of leaving work is known that it does not generally happen out of nowhere; the negative views of employees with regard to their work develop over time and happens when they decide to start a better work (Chau et al., 2009). Therefore, it is important to know whether the employees have the intent to leave their work and if they do; some measures should be taken upon the identification of reasons that cause such circumstance. In consideration with the literature review, the studies that focus on the factors affecting the intent to leave mainly focus on the variables of personal characteristics, work stress, work satisfaction, exhaustion, satisfaction with the wage and performance (Barrett & Yates, 2002; Castle et al., 2007; Estryn-Behar et al., 2007; Faller et al., 2011; Han et al., 2009; Labrague et al., 2018); on the other hand, the studies that analyse the relationship between the emotional labour and intent to leave work are limited (Kim & Lee, 2014; Lee & Lee, 2011).

It is important to analyse whether the emotional labour has a direct effect on the intent to leave work but also research focusing on whether the employee performance has a mediating effect on such relationship would provide sound information about the relationship between two variables. According to the existing studies, employee performance has an effect on the intent to leave and the rates of leaving work decrease as the performance levels increase (Abualrab & Al-Zaru, 2008; Goodwin et al., 2011). However, there are not any studies that evaluate the effect of emotional labour levels among nurses on the intent to leave together with the performance. Consequently, the results from this study are considered to fill a gap in the literature.

Methods

Aim

This study is conducted to analyse the relationship between the emotional labour and intent to leave their work among nurses, and to identify whether there is any mediating effect of employee performance on the relationship between emotional labour and intent to leave.

The hypotheses that would be tested to conduct such aim are as follows:

H_1a: Surface acting will be negatively associated with performance level.

H_1b: Deep acting will be positively associated with performance level.

H_2a: Surface acting will be positively associated with intent to leave work.

H_2b: ‘Deep acting will be negatively associated with intent to leave work.

H₃: The employee performance has a mediating effect on the relationship between the surface and deep acting of nurses and intent to leave their work.

Design

A descriptive cross-sectional study conducted through self-completed survey was undertaken using a sample of nurse in Turkey.

Sample

The research population is comprised of 278 nurses, who are actively working at a 320-bedded state training and research hospital in Turkey. No sample was selected for this research with the aim of reaching all nurses, yet only 220 nurses (79%) voluntarily participated to the research. Upon taking the permission of hospital management for the performance of research, face-to-face interviews were conducted with the nurses, between January and June 2018 and each interview took 5–10 minutes.

Data Collection

The survey method was used as a data collection tool. The first part of survey, which has four parts, is comprised of questions for the identification of personal characteristics of nurses. In order to measure the emotional labour levels of nurses, the second part includes the surface acting and deep acting as the subscales of ‘Emotional Labor Scale’ developed by Diefendorff et al. (2005). Although the surface acting subscale measures the emotional labour through the side of employee where he/she shows fake and different emotions rather than the real emotions within the framework of institutional and professional rules; the deep-acting subscale measures the side of employee where he/she show an effort to play the role as an actor and reflect the emotions as a result of such effort. A high score taken from surface acting and deep-acting subscales indicate that the emotional labour is high accordingly.

The third part of survey includes ‘Employee Performance Scale’, which was created by merging four items from the scale developed by Kirkman and Rosen (1999) and two items from the scale developed by Rahman and Bullock (2005). A high score from the scale reflects that the employee perceives high performance level.

The fourth part of survey includes ‘Intent to Leave Work Scale’, which was created by merging three items from the scale developed by Wayne et al. (1997), three items from the scale developed by Lum et al. (1998) and two items from the scale developed by Süner (2014) in order to measure the intent to leave their work among nurses. A high score from the scale means that the employee has a high level of intent to leave the work.

Data Analysis

A two-step procedure of analysis was followed in the data analysis. Within the scope of first phase, a first-level confirmatory factor analysis was conducted to identify whether ten items were used to measure the emotional labour levels of nurses participated to the research, six items were used to measure the employee performance and eight items were used to measure the intent to leave the work are valid to measure such latent constructs. Based on the confirmatory factor analysis, in order to test the goodness of fit of measurement models that belong to the relevant latent constructs, chi-square/df, Comparative Fit Index (CFI), Non-normed Fit Index (NFI), Tucker–Lewis Index (TLI) and Root Mean Square Error of Approximation (RMSEA) values were used, which are widely used in the literature. An acceptable goodness of fit is considered to be available where the chi-square/df value is below 3; CFI, NFI and TLI are above 0.90 and RMSEA is below 0.80 so that the data are fit for the model (Engel & Moosbrugger, 2003). Additionally, the internal consistency coefficient was also calculated in order to decide on the reliability of items used to measure the latent constructs. For the second phase, the Structural Equation Model (SEM) was utilised in order to test the hypotheses relationships. Through SEM, it was investigated whether there was a relationship between the emotional labour levels of nurses and their intent to leave work, whether the performance of nurses had a mediating effect on this relationship, and whether the intent to leave work differentiated according to the work experience of the nurses. Pursuant to Baron and Kenny (1986), three conditions should be available in order to mention a mediating effect as (a) the independent variable (emotional labour) should have a significant effect on the mediating variable (performance), (b) the independent variable (emotional labour) should have a significant effect on the dependent variable (intent to leave) and (c) the mediating variable should have a significant effect on the dependent variable (intent to leave) while the effect of independent variable (emotional labour) on the dependent variable (intent to leave) diminishes. A three-model approach was used to verify whether the employee performance has a mediating effect between the emotional labour and intent to leave (Anderson & Gerbing, 1988). These models are (a) partially mediated model; the emotional labour of nurses would directly affect the intent to leave the work and indirectly effect the intent to leave the work through employee performance, (b) fully mediated model; the emotional labour would not directly affect the intent to leave the work, but only indirectly affect through the employee performance and (c) direct effect model; the emotional labour and employee performance would have direct effects on the intent to leave the work.

Results

Considering the research, more than half of the participant nurses (54.1%) have bachelor and post-graduate education with the age average 36.1 that have a work experience of 15 years with 8 years in this hospital, respectively. Since there is a high correlation between the age of nurses and work experience (r = 0.910; p < .001), the work experience variable was added to the structural equation.

Figure 1 shows the measurement models and goodness of fit values with regard to the scales used to identify the surface and deep-acting levels of nurses that are within the scope of research, their performance and intents to leave the work. Consequently, the factor loads (the correlation coefficient showing the relationship of each item with the related dimension) of items representing the surface and deep-acting dimensions are above 0.50 and t values are significant (p < .001). In consideration with the goodness of fit values regarding both models, the chi-square/df (x²/df = 2.52) and RMSEA (0.08) values of deep-acting model have acceptable fit value, while CFI (0.99), TLI (0.98) and NFI (0.99) values are at perfect level. Moreover, the chi-square/df value (x²/df = 1.86) of surface-acting dimension is within the acceptable levels while other goodness of fit values (CFI = 0.99; TLI = 0.98; NFI = 0.98; RMSEA = 0.06) indicate a perfect fit level. Consequently, both dimensions were considered as suitable to use in the structural model.

Figure 1.

Measurement Models Regarding the Surface and Deep Acting, Employee Performance and Intent to Leave Among the Participant Nurses.

Pursuant to the factor loads of items representing the performance levels of nurses, the factor load of first item was observed as above 0.439, whereas the factor loads of other five items were above 0.50. Hence, it was decided to remove the first item from the measurement model on the performance latent variable (employee performance) and to measure the performance levels of nurses with the remaining five items. The chi-square/df (x²/df = 2.24) and RMSEA (0.07) values of model indicates a good fit, whereas CFI (0.99), NFI (0.98) and TLI (0.98) shows a perfect fit.

Considering the factor loads of eight items used to measure the intents to leave among employees, the factor loads of items other than the fifth item (–0.330) are above 0.50, and the t values are significant (p < .001). Therefore, it was decided to remove the fifth item and use the remaining seven items in the explanation of intent to leave the work latent variable. Similar to other models, the chi-square/df (x²/df = 1.41) fit index values are acceptable in the intent to leave model; and the fit indices values of CFI (0.99), NFI (0.99), TLI (0.98) and RMSEA (0.04) are at the perfect level. Hence, the seven items used to measure the intent to leave level are considered to sufficiently represent the relevant latent variable; the proposed measurement model is suitable for the research data and the construct validity is ensured.

After the identification of structural validity of the expressions used to measure the emotional labour, employee performance and intent to leave of the nurses under the scope of research in the measurement of such latent variables, the reliability levels were also analysed as seen in Table 1 and the Cronbach alfa coefficient for the Emotional Labour Scale was calculated as 0.872, 0.900 for the Employee Performance Scale, 0.934 for the Intent to Leave Work Scale, and the measurements were identified as above the acceptable levels in terms of reliability.

Table 1.

Reliability Results from the Scales of Emotional Labour, Employee Performance and Intent to Leave Work.

Scales & Dimensions	Number of Items	Cronbach Alpha
Emotional labour scale reliability level	10	0.872
Surface-acting dimension	6	0.909
Deep-acting dimension	4	0.911
Employee performance scale reliability level	5	0.900
Intent to leave scale reliability level	7	0.934

After it is identified that the confirmatory factor analyses can define the surface and deep-acting levels of participant nurses, their performance levels and intents to leave their work in a valid manner; a path analysis regarding the identification of factors that affecting the intent to leave the work among nurses was performed. Figure 2 shows the path analysis explaining the intent to leave the work among nurses. As it can be seen from the figure, the surface and deep-acting levels of nurses, and work experience are the explanatory variables of structural model while the employee performance is the mediating variable and the intent to leave is the endogenous variable. In consideration of the effect of surface and deep-acting levels among nurses on their performances (H_1a and H_1b were supported), the surface-acting dimension has a negative and significant effect on the performance levels (t = −5.022; p < .001), whereas the deep-acting dimension has a positive and significant effect (t = 2.135; p = .033). With regard to the direct effect of surface and deep acting on the intent to leave the work (H_2a and H_2b were supported), the surface-acting dimension has a positive and significant direct effect (t = 3.055; p = .002), whereas the deep-acting dimension has negative and significant direct effect on the intent to leave the work (t = −3.358; p < .001). Pursuant to the analysis that whether the work performance has any mediating effect on the relationship between surface and deep-acting levels of nurses, and the intent to leave the work; the employee performance variable has a partial mediating effect since the surface and deep acting directly affect the intent to leave and indirectly through the employee performance (H₃ was supported). Additionally, the work experience of nurses was identified to have negative and significant relationship with the intent to leave (t = −2.891; p = .004).

Figure 2.

Note: X²/df = 2.75; CFI = 0.89; TLI = 0.88; NFI = 0.85; RMSEA = 0.09.

Discussion

Since the healthcare institutions are labour intense organisations, the effect of employees on the institutional performance is higher when compared with the other institutions. Therefore, the performance on studies regarding the identification of attitudes and behaviours of employees such as their emotions, ideas, performances and intent to leave their work are crucial for the managers. This study aims to reflect the effect of emotional labour levels and work experience of nurses on the intent to leave and whether the employee performance has any mediating effect on such effect accordingly.

Pursuant to the SEM generated within the scope of research, the surface and deep-acting dimensions of nurses that show the emotional labour levels of nurses has a direct effect on the performance (Table 2). Hence, it is identified that the performances of employees decrease as the surface-acting levels increase while the performances increase as the deep-acting levels increase, respectively. Grandey et al. (2005) explain the surface acting with the artificial behaviours of employees and the deep acting with their sincerity. Pursuant to this view, the artificial behaviours of surface-acting employees can be felt by the patients and the performance diminishes since the patients would not want to get services from the same service providers. On the other hand, the behaviours of deep-acting employees have a positive effect on the performance as patients do not notice such behaviours and consider the employees sincere. Similar to this study, the study conducted by Ghalandari et al. (2012) on the nurses reflected that the surface-acting levels of nurses negatively affect the performance while the deep-acting levels affect the performance in a positive way. Pursuant to the study conducted by Liu et al. (2013) on the personnel working in the service sector, the relationship between performance and surface acting is negative and the deep acting as positive. Similarly, the study by Goodwin et al. (2011) showed that the surface-acting dimension has negative effect on the performance and the affective delivery variable has a complete mediating effect. A study by Lin and Chang (2015) conducted on 530 physicians indicated that the deep acting has not any direct effect on performance while the surface acting has a direct and negative effect on performance. However, the emotional exhaustion variable has a complete mediating effect between deep acting and performance.

Table 2.

Structural Equation Model Findings on the Factors Affecting the Intent to Leave Work Among Employees.

Variables			Unstandardised Regression Weights	Standardised Regression Weights	SE	C.R.	P
Performance	<—	Surface	−0.417	−0.387	0.083	−5.022	<.001
Performance	<—	Deep	0.150	0.155	0.07	2.135	.033
Intent to leave	<—	Surface	0.270	0.246	0.088	3.055	.002
Intent to leave	<—	Deep	−0.244	−0.247	0.073	−3.358	<.001
Intent to leave	<—	Performance	−0.150	−0.148	0.075	−2.011	.044
Intent to leave	<—	Work experience	−0.029	−0.188	0.01	−2.891	.004
SU_Q6	<—	Surface	0.961	0.813	0.071	13.616	<.001
SU_Q5	<—	Surface	1	0.827
SU_Q4	<—	Surface	0.946	0.777	0.061	15.488	<.001
SU_Q3	<—	Surface	0.846	0.758	0.072	11.753	<.001
SU_Q2	<—	Surface	0.915	0.797	0.071	12.944	<.001
SU_Q1	<—	Surface	0.881	0.707	0.081	10.904	<.001
DA_Q9	<—	Deep	0.924	0.886	0.051	18.016	<.001
DA_Q10	<—	Deep	0.932	0.845	0.056	16.571	<.001
DA_Q7	<—	Deep	0.865	0.773	0.06	14.521	<.001
DA_Q8	<—	Deep	1	0.893
EP_Q2	<—	Performance	0.655	0.612	0.063	10.458	<.001
EP_Q3	<—	Performance	0.862	0.872	0.043	19.985	<.001
EP_Q4	<—	Performance	1	0.954
EP_Q5	<—	Performance	0.653	0.751	0.045	14.669	<.001
EP_Q6	<—	Performance	0.717	0.789	0.046	15.707	<.001
IL_Q1	<—	Intent to leave	0.927	0.783	0.061	15.099	<.001
IL_Q2	<—	Intent to leave	0.790	0.734	0.058	13.555	<.001
IL_Q3	<—	Intent to leave	1	0.893
IL_Q4	<—	Intent to leave	1.015	0.895	0.051	20.014	<.001
IL_Q6	<—	Intent to leave	0.895	0.803	0.057	15.665	<.001
IL_Q7	<—	Intent to leave	0.779	0.73	0.059	13.112	<.001
IL_Q8	<—	Intent to leave	1	0.873	0.055	18.243	<.001

Note: SU: surface acting; DA: deep acting; EP: employee performance; IL: intent to leave; SE: standard error; C.R.: capability ratio; P: probability.

The research also analysed the direct effect of emotional labour levels of nurses (surface and deep acting) on the intent to leave, and the surface acting was found to have positive and deep acting to have negative direct effect on the intent to leave the work among nurses. Consequently, the intent to leave the work among nurses increases as the surface-acting levels increase while the intent to leave work decreases as the deep-acting levels increase, respectively. Similarly, the study by Ogungbamila et al. (2014) conducted on the healthcare professionals showed that the emotional labour has a direct effect on the intent to leave. The study by Çelik and Yıldız (2011) conducted on the nurses stated that the surface and deep acting have direct effect on the intent to leave the work. On the other hand, the study by Tsai et al. (2017) performed on the healthcare professionals indicated that the emotional labour has not any effect on the intent to leave the work.

Within the scope of research, the partial mediating effect of performance variable on the relationship between the surface and deep acting, and intent to leave the work was identified accordingly. The study by Hong and Lee (2016) conducted on the nurses showed that the emotional labour does not have any direct effect on the intent to leave the work while the emotional intelligence has a complete mediating role on the relationship between the emotional labour and intent to leave the work. Unlike such studies, a study by Goodwin et al. (2011) reflected that the emotional intelligence does not have any mediating effect on the relationship between the emotional labour and intent to leave the work.

Pursuant to the research findings, there is a statistically significant relationship between the work experience and intent to leave the work among nurses and the intents to leave work among nurses show a tendency to diminish as their work experience increase. It is considered that the efforts of employee increase, as the work experience is longer; hence the employee cannot easily abandon his/her contribution and institution. Therefore, there might be a reverse relationship between the work experience and intent to leave the work. Similarly, the study by Hart (2005) conducted on 463 nurses showed that the intent to leave the work diminish as the work experience is longer. Pursuant to the study of Mrrayan (2005) regarding nurse, there is a negative relationship between the work experience and intent to leave the work. On the other hand, the study by Singh and Loncar (2010) conducted on 200 nurses showed that the intent to leave the work among nurses diminishes as their work experience is longer. However, the study by Liou and Cheng (2010) conducted on 486 nurses working in Taiwan indicated that the nurses with <1 year work experience have lower intent to leave the work. Unlike such results, Labrague et al. (2018) conducted a study on 166 nurses and did not find any relationship between the work experience and intent to leave the work. Similarly, the study by Kalifa et al. (2016) regarding the healthcare professionals did not identify any relationship between the work experience and intent to leave the work.

Pursuant to such findings, there are studies under the literature that support the outcome of this study (Çelik & Yıldız, 2011; Ghalandari et al., 2012; Hart, 2005; Hong et al., 2016; Lin & Chang, 2015; Liu et al., 2013; Mrrayan, 2005; Ogungbamila et al., 2014; Singh & Loncar, 2010), there are also some research that reflect different findings than this study (Kalifa et al., 2016; Labrague et al., 2018; Liou & Cheng, 2010; Tsai et al., 2017). Such differences may be resulted from the occupational groups and healthcare institutions covered under the studies but also due to the sample volume, data collection tool and application method, and differences in the analysis methodology.

Conclusion

From this study, the performance levels of surface-acting nurses are lower but their intents to leave the work levels are higher. According to this finding, the hospital managers should design the work environment and conditions in a way that would prevent surface acting in order to enhance the performances of nurses and diminish their intents to leave the work. On the other hand, the knowledge, skills and demands of nurses should be considered in the work distribution. Finally, the hospital managers should organise seminars or trainings about patient communication towards the nurses with higher surface-acting tendency. According to the study findings, hospital managers should implement interventions specifically targeted at nurses with limited work experience to reduce their intention to leave the work. Within this framework, a number of activities such as regular measurement of relevant employees’ performance levels and provision of incentives that would minimise the factors causing the decrease in performance, and would improve their commitment to the institution.

Since this research was conducted on the nurses from one training and research hospital, the approach should be prudent in the generalisation of outcomes to the nurses working at other hospitals. Therefore, there should be more studies that cover more hospitals in order to reach outcomes with stronger external validity. Moreover, this study is considered to provide significant hints that show the groups with higher levels of intent to leave the work.

Implications for Nursing Management

Nurses act as a bridge between patients and their relatives and other healthcare providers in healthcare delivery. Especially because of the inadequate number of nurses in countries such as Turkey (2.3 nurses per 1,000 people for 2018) show an increase in workload, they engage in irregular and long working hours and quite a stressful job because also meet the emotional needs of patients. For this reason, in order to prevent the decrease in the number of nurses, which are currently inadequate, due to such reasons, the nurses’ intention to quit should be determined in advance by the managers. Thus, the effects caused by the high emotional burden will prevent the emergence of more important problems such as low performance and quitting with the administrative steps to be taken. At this point, it is suggested that it may be beneficial for nurse managers to organise trainings in their units, to evaluate the performance of nurses at regular intervals and thus to determine the reason for the increase and decrease, to plan activities that will reduce emotional burden, to determine working hours and shifts by taking the nurses’ opinion.

Footnotes

Acknowledgements

No acknowledgements have been declared by the authors.

Authorship Statement

All authors listed have met the criteria for authorship, approved the final manuscript and agreed to be in the authorship team. B. Ş. provided substantial contributions to the literature review, design of the study, data analysis and interpretation of the findings. G. İ. contributed to the study development, data collection, interpretation of findings and revision of the manuscript. S. S. contributed to the literature review, design of the study and revision of the manuscript.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Ethical Statements

Verbal consent of the hospital manager was obtained for the survey applied within the scope of this study. Written consent forms were obtained from each participant during the survey. Within the scope of the research, all participants were informed about the voluntary nature of participation and the confidentiality and anonymity of their information.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

Note on Previous Publication

A preliminary version of this work was previously presented as a conference paper [İlgün G., Sönmez S., & Şahin B. (2018). Investigation of performances in the context of nurses’ emotional levels. 2nd International 12th National Congress on Health and Hospital Administration. October 11-13 2018, Muğla, Turkey]. The present article represents an expanded and refined version of that work, incorporating additional analysis, extended discussions, and new findings. While there is some overlap in content with the earlier publication, this article provides a more comprehensive and in-depth treatment of the research topic. We believe that the current publication significantly enhances and extends the initial contribution, and we encourage readers to refer to this article for a more complete understanding of the research.

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