Healing leaders: Altruism and psychological safety as antidotes to burnout in health care settings
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Cite this article:
Wang, R., Ahmad, N., Ryu, H. B., Comite, U., Ariza-Montes, A., & Han, H.
(2024). Healing leaders: Altruism and psychological safety as antidotes to burnout in health care settings.
Social Behavior and Personality: An international journal,
52(12),
e13540.
Abstract
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Employee burnout is an issue of relevance to several of the United Nations’ sustainable development goals. We investigated servant leadership, psychological safety, and employee altruism as important factors for predicting burnout in the Chinese health care sector. A three-phase questionnaire was administered to 412 health care professionals and data were analyzed using structural equation modeling. Servant leadership was found to positively predict psychological safety. In addition, servant leadership interacted with employee altruism to significantly predict burnout via the mediating variable of psychological safety. These outcomes indicate that servant leadership and a protective, caring organizational climate can be helpful in preventing burnout among health care workers. This has implications for academic research and gives rise to practical recommendations for health care leaders, in line with the aim of having a resilient and sustainable health care system by 2030.
Article Highlights
- The relationship between servant leadership and employee burnout in China’s health care sector was found to be mediated by psychological safety and moderated by employee altruism.
- Servant leadership negatively predicted burnout and has the potential to support the United Nations’ sustainable development goals relating to health, work, and well-being.
- Personalized leadership strategies may leverage employee altruism to help combat burnout.
Employee burnout, a significant problem confronting organizations in the present organizational environment, relates to several of the United Nations’ sustainable development goals (SDGs), including SDG 3 (Good Health and Well-Being) and SDG 8 (Decent Work and Economic Growth; Asante et al., 2019; Lei et al., 2023). Burnout, a syndrome resulting from prolonged workplace stress, affects individual health and organizational ethos and may also have implications for SDG 10 (Reduced Inequalities) and SDG 16 (Peace, Justice, and Strong Institutions; Yang & Hayes, 2020). Globally, burnout costs add up to USD 322 billion per year, a clear indication that this phenomenon is relevant to SDG 9 (Industry, Innovation, and Infrastructure; Bruce, 2019). In addition, burnout reduces service quality in sectors that are based on human interaction, including the health care sector, which relates to SDG 12 (Responsible Consumption and Production). Although burnout has been well studied, particularly in the health care field (where burnout was aggravated by the COVID-19 pandemic; U.S. Department of Health and Human Services, 2022), the roles of leadership styles (e.g., servant leadership), psychological safety, and employee traits in mitigating burnout have not been explored in depth. Recent research has focused on the different dimensions of these mutual relationships.
Servant leadership is a philosophy in which a leader’s main goal is to serve others, with a focus on supporting and empowering team members (Greenleaf, 1998). Wang et al. (2022) found that servant leadership creates room for creativity among employees through promoting psychological safety and well-being. These findings underline the potential for servant leadership to cultivate conducive environments for creativity, yet they leave unexplored the specific impacts on burnout within high-stress sectors such as health care. Psychological safety means that people are confident to put forward relevant ideas, questions, concerns, or mistakes without fear of consequences (Edmondson, 1999). Brohi et al. (2021) and Ma et al. (2021) highlighted the role of psychological safety in reducing burnout and turnover intention while increasing trust. Additionally, Bai et al. (2023) found that psychological safety and job burnout mediated the relationship between servant leadership and the affective commitment of hospital staff in China, with job burnout acting as a critical mediator. These studies collectively advance our understanding of the potential positive consequences of servant leadership but do not explain how specific employee traits, such as altruism, interact within these dynamics. Employee altruism, which is defined as the caring and selfless concern that an employee shows for others, is compatible with servant leadership and leads to a culture that provides psychological safety and reduces burnout (Guan et al., 2023). This reciprocal culture suggests that altruistic employees may be more receptive to servant leadership and hence aid servant leaders in creating an organizational culture of safety and well-being (Azila-Gbettor, 2023).
Our research aimed to address the identified gaps by investigating psychological safety as a mediator of the relationship between servant leadership and burnout, with an empirical emphasis on employee altruism as a moderator in this relationship. Investigating this theoretical model in the Chinese health care setting is novel. A main idea is that different levels of employee altruism could impact the effectiveness of servant leadership in curbing burnout. This consideration is essential for a comprehensive understanding of burnout in the context of SDGs and to explore how leadership styles and the personal characteristics of employees interrelate in an industry prone to severe and long-term stress. The goal of our approach, in contrast to previous literature (e.g., Bai et al., 2023; Brohi et al., 2021; Ma et al., 2021; Wang et al., 2022), lies in its determination of the moderating role of altruism in the relationship between servant leadership and burnout, and in offering insights into personalized and SDG-aligned leadership strategies that promote health, work, and well-being.
Conservation of resources (COR) theory (Hobfoll, 1989) offers the basic structure for analyzing employee burnout in health care settings. This theory is centered on the human drive to acquire and protect valuable resources and suggests that resource loss has a more profound psychological impact on individuals than the equivalent gains (Chen et al., 2022). Servant leadership focuses on employee wellness and can be seen as a potential resource of employees, for whom burnout is often associated with resource depletion (Iqbal et al., 2020). Servant leadership is characterized by solving follower needs and is useful in the high-stress health care field for reducing burnout, emotional exhaustion, cynicism, and low efficacy (Al-Asadi et al., 2019). COR theory suggests that servant leadership reduces stress and burnout by increasing levels of motivation, self-efficacy, and communication. Similarly, altruism among employees can activate a reciprocal cycle of resource sharing under servant leadership. This exchange amplifies emotional and psychological support, creating a resilient environment that helps prevent burnout (Ahmed et al., 2023). Hence, we proposed the following hypothesis:
Hypothesis 1: Servant leadership will be negatively related to employee burnout in the health care sector.
Psychological safety means that employees are willing and confident to make mistakes, seek feedback about their performance, openly express their thoughts, and talk about errors without facing adverse consequences and punishment (Edmondson, 1999). Psychological safety is associated with beneficial individual outcomes such as work engagement and creativity (Ahmad et al., 2022). Thus, it is essential for servant leadership to actively foster an environment of psychological safety, where employees feel secure and valued. Perceptions of psychological safety might be influenced by leaders who are open-minded, coaching, and nonjudgmental (Brohi et al., 2021). Consistent with this, the core traits of servant leaders, who are supportive and nonhostile, may promote psychological safety (Brohi et al., 2021). Several empirical studies (see, e.g., Schaubroeck et al., 2011) have found employees’ perceptions of psychological safety to be positively correlated with servant leadership.
Servant leadership is vital for ensuring workers have access to resources such as psychological safety, which, according to COR theory, is a prerequisite for resilience against workplace stressors (Ahmed et al., 2023). While often overlooked, servant leadership strengthens the psychological resources of employees against burnout and creates a secure, confidence-inspiring environment (Ma et al., 2021). Positive psychology in the workplace is also well supported by this leadership style, promoting optimism and resilience (Dutta & Khatri, 2017). This led us to propose the following hypothesis:
Hypothesis 2: Servant leadership will be positively related to employees’ perception of psychological safety.
Psychological safety, which is particularly relevant in health care settings, has been increasingly topical in recent years (O’Donovan & McAuliffe, 2020). Health care professionals should feel free to raise concerns, seek advice, and admit mistakes without fear (Vévoda et al., 2016). A psychologically safe environment not only prevents employee burnout but also conserves and replenishes resources (Zhou & Chen, 2021). Resources in health care span from tangible ones, such as time, equipment, and support, to intangible ones, such as recognition (Ahmed et al., 2023). Psychological safety is itself considered a resource; when their psychological safety is lost or threatened, individuals may experience increased stress and possibly burnout (Ahmed et al., 2023). Hence, we proposed the following hypothesis:
Hypothesis 3: Psychological safety in health care settings will be negatively related to employee burnout.
The relationship between servant leadership and employee burnout is complex and may be influenced by factors such as organizational culture, employee autonomy, and the nature of job demands (Ma et al., 2021). This relationship may be mediated by psychological safety, in that the meaningful communication channels and zero-hostility atmosphere initiated by servant leadership (Ahmed et al., 2023) might reduce the problem of employee overwork and burnout. The servant leadership approach, with its emphasis on empathy, awareness, and subordinates’ welfare, develops a tolerant environment where employees become noticed and feel psychologically safe (Peng et al., 2022). Ahmed et al. (2023) defined a psychologically safe workplace as one in which employees do not hesitate to admit their mistakes and can share their innovative thoughts without the fear of being judged. This, in turn, renders the employees more capable of dealing with work-related stresses and protects them from burnout. Servant leadership may therefore help to create a work atmosphere characterized by reduced rates of burnout. Hence, we proposed the following hypothesis:
Hypothesis 4: The relationship between servant leadership and employee burnout will be mediated by psychological safety.
Employee behavior and attitudes can be guided by work values that are altruistic, emphasizing community and societal well-being rather than personal benefit (Lee et al., 2014). Altruistic employees are naturally motivated to help others; thus, they are selfless, and the emphasis that servant leadership places on followers’ needs would likely resonate with them (Ahmad, Ahmad, et al., 2023). Servant leadership functions as a positive resource within the COR framework, fostering understanding and empathy for employees and leading to enhanced self-value and psychological safety. Employee altruism may moderate the relationships between servant leadership, psychological safety, and employee burnout. While servant leaders are characterized by high levels of altruism, it is important to clarify that in our model, altruism functions independently as a moderator rather than being directly influenced by servant leadership. Employees with intrinsic altruistic tendencies may find that servant leadership supports their ability to manage workplace stress more effectively through increasing psychological safety, thereby helping to prevent burnout (Ma et al., 2021). Therefore, we proposed the following hypothesis:
Hypothesis 5: Employee altruism will moderate the indirect relationship between servant leadership and employee burnout, with this indirect association being stronger when altruism levels are higher.
Method
Participants and Procedure
We focused our study on health care professionals in Beijing, Shanghai, and Chengdu, within the People’s Republic of China. Prior to the commencement of this project, we obtained approval from seven hospital authorities from these cities, conforming to institutional and ethical standards. In line with the Helsinki Declaration, our participants (i.e., health care professionals) were guaranteed optimal care and confidentiality in data management. The research was conducted using a three-wave, paper-and-pencil survey over the duration of 6 weeks, with breaks of 2 weeks in between each wave. The first wave concentrated on servant leadership and measured employees’ perception of their leaders’ behavior. The second wave concentrated on psychological safety. In the third wave we measured burnout and altruism. Responses to the surveys were recorded in person to maximize engagement. While participants were not financially compensated, they received a summary of the study results, which offered insights into combating workplace burnout. Table 1 presents the demographic data for our sample.
Table 1. Sample Demographics
Measures
This study employed an adapted questionnaire, originally validated in prior research, to measure the four key variables of servant leadership, burnout, psychological safety, and altruism. All items were rated on a 5-point Likert scale ranging from 1 = strongly disagree to 5 = strongly agree. Servant leadership was measured using seven items (e.g., “My leader puts my best interests ahead of their own”) adapted from Liden et al. (2015), burnout was measured using seven items (e.g., “I feel worn out at the end of the working day”) from Kristensen et al. (2005), psychological safety was measured using seven items (e.g., “No one in this hospital would deliberately act in a way that undermines my efforts”) from Edmondson (1999), and altruism was measured using three items (e.g., “I joined health care as a profession to help others”) from Dotson et al. (2014).
We followed various approaches to establish the validity of our measures and avoid common method bias and social desirability bias. For example, we ensured confidentiality in the survey, rotated the question order to diminish the risk of patterned responses, and encouraged the participants to be honest, to help ensure that all input was valid. Harman’s single-factor test demonstrated only minor common method bias in our data (Ahmad, Samad, et al., 2023).
The sample size was determined using an a priori sampling calculator for structural equation modeling, which is important for guaranteeing statistical sufficiency in a partial least squares structural equation modeling analysis. On the basis of the number of constructs, expected effect sizes, and number of items per measure, the suggested minimum sample size was 376. To account for possible nonrespondents and missing data, we distributed 600 questionnaires in different hospital departments. Three waves of data collection were followed by data screening for completeness and consistency. The final valid response count was 412, exceeding the recommended sample size. This not only supported our study’s robustness and generalizability but also our use of partial least squares structural equation modeling in estimating multiple relationships simultaneously.
Results
A confirmatory factor analysis (see Table 2) revealed that most factor loadings were greater than .70. One item from the psychological safety measure had a weak factor loading (.46) and was consequently removed.
Table 2. Confirmatory Factor Analysis Results
Next, we assessed the robustness and reliability of our constructs (shown in Table 3). Cronbach’s alpha, rho_A, and composite reliability values indicated that the consistency and reliability of the constructs were acceptable. The average variance extracted (AVE) values suggested that > 50% of the variance in the latent variables was captured.
Table 3. Reliability and Validity of Constructs
Note. AL = altruism; BO = burnout; PS = psychological safety; SL = servant leadership; CR = composite reliability; AVE = average variance extracted.
Table 4 shows the intercorrelations and square roots of the AVE values for altruism, burnout, psychological safety, and servant leadership. The square root of AVE for each construct was higher than the corresponding interconstruct correlations, indicating adequate discriminant validity.
Table 4. Descriptive Data, Correlations, and Divergent Validity
Note. The diagonal values represent the square roots of average variance extracted. All correlation values were significant at p < .05.
Table 5 provides the heterotrait–monotrait ratios for altruism, burnout, psychological safety, and servant leadership, as further evidence of discriminant validity. All ratios were below .85, indicating the distinctiveness of the constructs.
Table 5. Heterotrait–Monotrait Ratios
The results of our hypothesis testing (conducted using Smart-PLS) are presented in Table 6, with the structural model displayed in Figure 1. Servant leadership was inversely related to burnout, and positively related to psychological safety, supporting Hypotheses 1 and 2. Psychological safety was negatively related to burnout and significantly mediated the relationship between servant leadership and burnout, supporting Hypotheses 3 and 4. A significant moderated mediation effect indicated that the relationship between servant leadership and psychological safety varied across levels of altruism, supporting Hypothesis 5. Lower altruism was associated with a weaker relationship between servant leadership and psychological safety, while higher altruism was associated with a stronger relationship. These results, presented in Figure 2, demonstrate that there was a moderating effect of altruism on the relationship between servant leadership and psychological safety.
Table 6. Structural Analysis: Direct Effects, Mediated Effect, and Moderated Mediation
Note. PS = psychological safety; BO = burnout; SL = servant leadership; AL = altruism; CI = confidence interval; LL = lower limit; UL = upper limit.
Figure 1. Structural Model
Note. SL = servant leadership; AL = altruism; PS = psychological safety; BO = burnout.
** p < .01. *** p < .001.
Figure 2. Interaction Effect of Servant Leadership and Altruism on Psychological Safety
Discussion
Our investigation focused on the complex relationship between servant leadership and employee burnout, regulated by psychological safety and employee altruism, within the health care sector of China. Supporting Hypothesis 1, we found a significant inverse relationship between servant leadership and burnout. This relationship supports prior research by Al-Asadi et al. (2019), indicating that positive work conditions such as servant leadership can have mitigating effects on stress and burnout. Furthermore, we found a positive association of servant leadership with psychological safety, supporting Hypothesis 2. This outcome contributes to discussions about the relationships between leaders’ actions and the creation of a workplace that promotes worker well-being and stress management. Our finding is in line with Brohi et al. (2021), who mentioned that a core trait of the servant leader is providing a supportive and nonhostile working environment that promotes psychological safety. We also observed a critical role of psychological safety in reducing employee burnout in the health care context, hence supporting Hypothesis 3. In line with Zhou and Chen (2021), our results suggest that a psychologically safe working environment encourages health care workers, thereby reducing burnout.
Probing further, our research demonstrated the role of psychological safety as a mediating variable (Hypothesis 4), supporting Ma et al. (2021), who reported that creating a work environment built upon open communication and free of retaliation is crucial for stress management and improving the psychological safety of employees, which ultimately protects against employee burnout. The mediating role of psychological safety emphasizes its effectiveness in developing a culture in which employees feel safe to express their concerns and admit mistakes without any fear of being retaliated against.
We found that when there were higher levels of altruism, the relationship between servant leadership and psychological safety was stronger. This is consistent with, and advances, Edmondson’s (1999) view of psychological safety by demonstrating how it can be enhanced through the interaction between specific leadership styles—in this case, servant leadership—and employee characteristics such as altruism. The role of altruism as a moderator additionally emphasizes the importance of selecting for and developing certain employee character traits within organizations to maximize leadership efficiency and organizational health.
Our work extends existing research by exploring how altruism serves as a moderator of the relationship between servant leadership and burnout, as mediated by psychological safety. While our research has implications for SDGs relating to health and well-being, economic growth, and decent work, our main concern was to examine the relationships between styles of management, psychological safety, and employee traits in health care institutions. This special focus makes a distinct contribution by revealing the ways in which various levels of altruism among employees can assist servant leadership in producing psychologically safe and burnout-resistant workplace environments. Our findings not only have practical relevance for leadership development and culture change within organizations but also suggest the need for nurturing environments in which altruistic behaviors are valued and encouraged. This selective strategy is important in improving the well-being and efficiency of health care workers, which indirectly helps in the achievement of SDGs related to health care sustainability.
Practical Implications
Our results have specific implications for health care institutions, particularly those in China, concerning the implementation of servant leadership to lessen the occurrence of employee burnout. Including this form of leadership as a key ingredient in health care organizations’ development programs may result in enhanced employee satisfaction and well-being. The adoption of servant leadership in health care institutions is a tool that is not only helpful in keeping burnout at bay but may also be instrumental in improving employee engagement and job satisfaction. Regarding psychological safety, our research calls for the construction of communication channels through which staff can freely raise their concerns and suggestions, thus improving the quality of patient care and reducing errors in hospital and outpatient settings. Bringing in acknowledgement and rewards for altruism in the context of leadership may further boost psychological safety and diminish burnout. By using recognition programs that reward benevolent behavior, health care organizations can build a culture in which altruism is nurtured. This perspective not only helps to improve the health and well-being of individual health care workers but also promotes teamwork and better patient care provision.
It is important to consider our findings within the context of SDGs. Improving health care workers’ wellness is directly linked to SDG 3 (Good Health and Well-Being) through creating more favorable work conditions and higher standards in patient care. On the other hand, the establishment of safe and supportive work environments is linked to SDG 8 (Decent Work and Economic Growth), which focuses on the need for good working conditions for sustainable economic growth.
Limitations and Future Research Directions
This study acknowledges limitations such as potential biases arising from self-reported data. The applicability of our results outside of China might be constrained by unique cultural and organizational practices. Future research could broaden the scope of this research by exploring diverse global health care environments, and incorporating qualitative methods to deepen the understanding of the roles of servant leadership, psychological safety, and altruism in mitigating burnout. Examining additional factors such as organizational support or group dynamics may offer more comprehensive insights into burnout-prevention strategies.
Conclusion
This study addresses a critical issue in China’s health care sector: widespread employee burnout. This issue of organizational psychology was explored through linking servant leadership, psychological safety, and employee altruism, with our results suggesting a need to reform existing systems. The mental health of health care professionals, patient care standards, and the sustainability of health care are jeopardized by burnout, which must be dealt with from a humanistic angle through approaches concerned with staff welfare and improvement, such as servant leadership. Leaders with empathy who engage in active listening and empower their subordinates should be trained in health care institutions. In addition, ensuring that workers can openly voice concerns and learn from their errors in a psychologically safe environment is imperative. Another way of combating burnout may be through encouraging and rewarding altruistic behavior among health care professionals. In addition, integrating digital resources for workload management and support may be beneficial.
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Table 1. Sample Demographics
Table 2. Confirmatory Factor Analysis Results
Table 3. Reliability and Validity of Constructs
Note. AL = altruism; BO = burnout; PS = psychological safety; SL = servant leadership; CR = composite reliability; AVE = average variance extracted.
Table 4. Descriptive Data, Correlations, and Divergent Validity
Note. The diagonal values represent the square roots of average variance extracted. All correlation values were significant at p < .05.
Table 5. Heterotrait–Monotrait Ratios
Table 6. Structural Analysis: Direct Effects, Mediated Effect, and Moderated Mediation
Note. PS = psychological safety; BO = burnout; SL = servant leadership; AL = altruism; CI = confidence interval; LL = lower limit; UL = upper limit.
Figure 1. Structural Model
Note. SL = servant leadership; AL = altruism; PS = psychological safety; BO = burnout.
** p < .01. *** p < .001.
Figure 2. Interaction Effect of Servant Leadership and Altruism on Psychological Safety
The data that support the findings of this study are available on request from the corresponding author.
Hyungseo Bobby Ryu, Foodservice and Culinary Art Department of the College of Health Sciences, Kyungnam University, Changwon-si, Gyeongsangnam-do 51767, Republic of Korea. Email: [email protected], or Heeesup Han, College of Hospitality and Tourism Management, Sejong University, 98 Gunja-Dong, Gwangjin-Gu, Seoul 143-747, Republic of Korea. Email: [email protected]
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