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.

First, participants will be administered a pre-test (Demographic Data Form, Burnout, Self-Leadership, Psychological Empowerment, and Psychological Resilience). Microsoft Excel will be used for random selection, and homogeneity will be ensured across groups based on the psychological resilience scores of the nurse managers. Randomization and intervention will be conducted by different researchers.

2.4.Sample Size The sample size was calculated using a power analysis program. The results indicated that a sample size of 56 participants (intervention = 28, control = 28) was sufficient to detect significant differences. Taking into account potential participant dropouts during the intervention process and follow-up test, a total of 60 nurse managers were planned to be selected for the sample, comprising 30 in the intervention group and 30 in the control group.

2.5.Psychosocial Empowerment Program for Nurse Managers (PEP-NM)

The Psychosocial Training Program for Empowering Nurse Managers is structured as two sessions, each lasting 45 minutes, over a five-week period. The program will be conducted by two full-time university faculty members/instructors, one holding a Ph.D. in Psychiatric Nursing and the other in Nursing Administration. The faculty member, who is an associate professor in psychiatric nursing, has completed training in MBSR and MBCT, Cognitive Behavioral Therapy (270 hours), and Acceptance and Commitment Therapy (36 hours).

The training content was developed around four themes, utilizing an approach derived from evidence-based theoretical frameworks and cognitive-behavioral therapy within the context of self-awareness and self-leadership. The content focuses on training and skill development . These four themes are burnout, self- leadership, psychological empowerment, and resilience.

To evaluate the program's appropriateness in terms of its purpose, objectives, and content, input will be sought from ten experts with experience and expertise in the field of mindfulness (including a psychiatric nurse, a faculty member specializing in nursing administration, a psychologist, and a mindfulness instructor). When gathering expert opinions, the Lawshe technique, frequently used in the literature, will be employed, and calculations will be performed according to the Content Validity Ratio (CVR) formula. According to the Lawshe technique, in studies where opinions are gathered from ten experts, the CVR for each item is expected to have a minimum value of 0.62.

During the training sessions, we will incorporate psychoeducation (PowerPoint presentations, brochures, homework assignments, etc.), self-reflection (discussion prompts, writing exercises, interpersonal sharing, etc.), and experiential learning (mindfulness meditation, art, trust-building activities, practical skills, etc.). In each session, topics related to burnout, self- leadership, psychological empowerment, and resilience will be the focus.

In addition, a WhatsApp group will be created to share short, training-specific content and reminders about the sessions. The group will also encourage participating head nurses to share group photos and evidence of their achievements. This initiative is designed to increase interaction among the research and training team, encourage one another, and maintain connections until the next session.

2.6.Data Collection Tools and Implementation 2.6.1.Personal Information Form This form was developed by researchers based on a literature review. It contains 15 questions regarding age, gender, marital status, number of children, income level, education level, department/clinic of employment, length of service as a professional and manager, and whether managers and charge nurses have received training in psychoeducation, leadership, and clinical leadership.

2.6.2.Maslach Burnout Inventory The Maslach Burnout Inventory consists of three subscales and 22 items. The subscales are: Emotional Exhaustion, Desensitization and Personal Accomplishment. In the Maslach Burnout Inventory, items related to emotional exhaustion and depersonalization are phrased negatively, while those related to personal accomplishment are phrased positively. The Turkish version of the Maslach Burnout Inventory, which has established validity and reliability, was used to assess burnout levels. The items in the scale consist of Likert-type, 5-point scale (never, very rarely, sometimes, most of the time, always) statements. Three separate scores are calculated for each individual. Since there are no cutoff values for the scores obtained from the subscales, when interpreting the data, the average scores are compared to indicate whether the burnout subscale score is higher or lower. Scoring is done on a scale where 0 = never and 4 = always; accordingly, the Emotional Exhaustion subscale ranges from a minimum of 0 points to a maximum of 36 points, the Depersonalization subscale ranges from a minimum of 0 points to a maximum of 20 points, and the Personal Accomplishment subscale ranges from a minimum of 0 points to a maximum of 32 points.

2.6.3.Self-Leadership Scale The Self-Leadership Scale, a 50-item instrument, was used to assess participants' self-leadership behaviors. The scale was later revised to improve its structure and validity. Reducing the number of items from 50 to 35. In this study, the Turkish version of the Self-Leadership Scale (Self Leadership Questionnaire), consisting of 29 items and adapted. The scale is organized on a 5-point Likert scale, with the following response options: (1) Strongly Disagree, (2) Disagree, (3) Undecided, (4) Agree, (5) Strongly Agree. A score ranging from a minimum of 29 to a maximum of 145 can be obtained on this scale.

2.6.4.Brief Psychological Resilience Scale (BPRS) The Short Psychological Resilience Scale (SPRS) is a 5-point Likert-type measurement tool consisting of six items, developed to assess individuals' psychological resilience. Each item on the scale is rated on a scale from "not at all agree" (1) to "strongly agree" (5). When scoring the scale, items 2, 4, and 6 are reverse-scored. A high score on the scale indicates a high level of psychological resilience, while a low score indicates a low level of psychological resilience. A score of 6-11 on the Brief Psychological Resilience Scale indicates a low level, 12-22 indicates a moderate level, and 23-30 indicates a high level (Hoşoğlu et al. 2018; Ünaldı, 2024).

2.6.5.Psychological Empowerment Scale The Psychological Empowerment Scale is consists of 3 subdimensions and 12 items. The Psychological Empowerment Scale is a Likert- type scale, with each item rated on a scale from 1 (strongly disagree) to 7 (strongly agree). Higher scores indicate higher levels of psychological empowerment .

2.7.Data Analysis SPSS version 23 will be used for data analysis. Skewness and kurtosis values will be examined to determine the normality of the data distribution. Descriptive statistics, including counts, percentages, means, and standard deviations, will be calculated. To compare the characteristics of the participants, descriptive statistics, the chi-square test, the independent samples t-test, and ANOVA will be applied. To compare the test results between the intervention and control groups, an independent samples t-test will be used; if the data are not normally distributed, the Mann-Whitney U test will be applied. To examine differences within groups, a Paired Samples t-test will be used; if the data are not normally distributed, the Wilcoxon Signed-Rank Test will be applied. To evaluate the effect of the intervention over time between the intervention and control groups and the time-group interaction, two-way repeated measures ANOVA will be used, and a post-hoc Bonferroni test will be applied to determine significant differences between groups. If the data are not normally distributed, generalized estimating equations (GEE) will be used to assess time-group interaction.

2.8.Ethical Considerations Ethical approval for the study was obtained from the Süleyman Demirel University Ethics Committee, and institutional permission was secured prior to the initiation of the research. Informed consent will be obtained from all participants before the study procedures begin.

Each participant will undergo a preliminary group interview to determine eligibility for participation in the intervention group. This interview will include an explanation of the study's purpose and objectives, an assessment of participants' willingness to take part in the program, and a review of the informed consent process.