A common concern for human service organizations is burnout caused by the high stress nature of providing services to others. Burnout is a stress-related psychological syndrome comprised of three components, emotional exhaustion, depersonalization, and personal accomplishment (Maslach and Jackson, 1981). Public sector mental health care providers are at high risk for burnout because these positions typically have high demands, low resources, and little reward (van Daalen et al. 2009). In the United States, recent funding constraints have led many agencies to increase productivity and billing requirements, thus adding more stress to already overburdened workers (Morse et al. 2011). The emotional demands of mental health positions are especially high (van Daalen et al. 2009), and are closely tied to burnout. Of the three components of burnout, emotional exhaustion, or the extent to which an employee lacks sufficient emotional resources to handle interpersonal stressors, is theorized to best capture the “core meaning” of burnout (Cropanzano et al. 2003; Shirom 1989).

Studies of burnout among mental health workers have found consistently high rates of emotional exhaustion (Paris and Hoge 2010) with negative consequences at both the employee and organization levels. Individual employees with higher burnout are more likely to experience poorer health (e.g., illness, depression, fatigue) and strained personal relationships (Knudsen et al. 2006; Morse et al. 2011; Salyers et al. 2011). At the organizational level, emotional exhaustion and burnout lead to poor job performance, increased absenteeism, and reduced client satisfaction with services (Knudsen et al. 2006; Morse et al. 2011). Emotional exhaustion has also been found to spread among providers within organizations, thus further increasing the negative effects of emotional exhaustion on the organization (Bakker et al. 2001).

Prior research has established a positive association between emotional exhaustion and turnover intention (Blankertz and Robinson 1997; Lee and Ashforth 1996; Mor Barak et al. 2001), and emotional exhaustion has been shown to predict future voluntary turnover (Wright and Cropanzano 1998). Turnover intention refers to the likelihood that an employee will leave their position in the near future. Although actual turnover may be involuntary or due to external factors (e.g., spousal job change, moving out of the area), most turnover is related to organizational or job-related factors (Mor Barak et al. 2001). Turnover intention is related to other withdrawal behaviors such as tardiness and absenteeism that negatively affect organizations (Halfhill et al. 2002) and is a strong and consistent predictor of actual turnover (Griffeth et al. 2000; Vandenberg and Nelson 1999).

Staff turnover is an ongoing and costly problem that negatively affects staff morale, team performance and productivity, and ultimately organizational effectiveness (Abbasi and Hollman 2000; Argote et al. 1995; Gray et al. 1996). Annual turnover rates in agencies providing mental health and social services can exceed 50% (Glisson et al. 2006), and have been attributed to factors including high stress environments, lack of support, and low pay (Aarons and Sawitzky 2006). In organizations providing clinical services, turnover can lead to disruptions in service provision and weaker staff-consumer relationships, therefore negatively affecting the quality and outcomes of services provided by these organizations and their staff (Albizu-García et al. 2004; Glisson et al. 2006; Knudsen et al. 2006). Reducing turnover intention among community mental health providers can help alleviate some of the costs associated with turnover and related behaviors, as well as improve the quality of services provided to clients.

In order to reduce turnover intention among employees, it is important to identify potential protective factors. One factor that may affect both emotional exhaustion and turnover intention is leadership of mental health program managers, in particular, transformational leadership (Aarons et al. 2011; Stordeur et al. 2001). Transformational leadership, as described by the full range model of leadership, is characterized by four leader behaviors—idealized influence, inspirational motivation, intellectual stimulation, and individual consideration (Bass 1990). Idealized influence is the extent to which a leader is admired, respected, and trusted. Inspirational motivation is the extent to which a leader promotes a common vision and provides meaning to the work of staff. Intellectual stimulation is the extent to which a leader stimulates staff to think in new ways and supports innovation and creativity, and individual consideration is the extent to which a leader takes into account the specific needs of individual employees and works to promote their growth and development (Bass 1990).

Transformational leadership is positively associated with several organizational processes and outcomes, including follower job performance, job satisfaction, organizational commitment, organizational citizenship behavior, and staff attitudes toward adopting evidence-based practices (Aarons 2006; MacKenzie et al. 2001; Walumbwa et al. 2005). Previous research has found that transformational leadership is negatively associated with both emotional exhaustion (Stordeur et al. 2001) and turnover intention (Bycio et al. 1995; Hughes et al. 2010; Rafferty and Griffin 2004) and moderates the effect of organizational climate on turnover intention (Aarons et al. 2011). Transformational leaders may help to reduce emotional exhaustion and turnover intention by strengthening group cohesion, increasing organizational commitment, and recognizing and rewarding the work done by followers. By providing support and inspiration, transformational leaders can buffer the negative effects of a stressful job environment (Stordeur et al. 2001). This may be especially beneficial for workers in the high stress field of mental health care.

While some predictors of transformational leadership such as extroversion and emotional stability are related to individual differences (Bono and Judge 2004), a number of studies have shown that training individuals in transformational leadership can lead to measurable behavioral change (Avolio and Bass 1998; Barling et al. 1996; Kelloway et al. 2000; Parry and Sinha 2005). Results of experimental and quasi-experimental studies have found that employees of leaders undergoing transformational leadership training report higher levels of leader intellectual stimulation, charisma, idealized attributes, idealized behavior, and individual consideration as well as higher subordinate organizational commitment, compared to a control group (Barling et al. 1996; Kelloway et al. 2000; Parry and Sinha 2005). Some common features of these leadership trainings include didactic training on leadership styles, 360-degree feedback (i.e., multi-rater assessment of leadership from self, subordinates, and supervisors), and individualized coaching and consultation. Given that such training programs can produce positive leader behavior change, it is important to examine the potential moderating role of transformational leadership in relation to organizational processes and individual differences in mental health service systems.

The current study examines the relationships between emotional exhaustion, turnover intention, and transformational leadership in a sample of public sector mental health care providers serving children, adolescents, and families. In accordance with previous literature, we hypothesized that emotional exhaustion will be positively related to turnover intention. We also predicted that transformational leadership will be negatively related to both emotional exhaustion and turnover intention. Finally, we hypothesized that transformational leadership will moderate the relationship between emotional exhaustion and turnover intention. Specifically, as transformational leadership increases, the relationship between emotional exhaustion and turnover intention will be attenuated.

Methods

Participants

Researchers invited 72 public sector programs providing mental health services for children, adolescents, and families to participate in the current study. Of the 72 eligible programs, 64 programs agreed to participate (89% response rate). However, data was not available on supervisor ratings for two of the participating programs. The total number of eligible participants from the participating programs was 440, of which 435 agreed to participate (98.9% response rate). Forty-seven of the participants were primarily supervisors and did not report on their own supervisor’s leadership behaviors resulting in a final sample of 388 community mental health providers.

Measures

Emotional Exhaustion

Emotional exhaustion was assessed using the Emotional Exhaustion subscale from the Children’s Services Survey (Glisson and James 2002) based on the Emotional Exhaustion subscale of the Maslach Burnout Inventory (Maslach et al. 1996). Examples of scale items include: “I feel emotionally drained from my work,” and “I feel used up at the end of the workday.” Participants indicated their level of agreement with each statement on a 5-point Likert-type scale from 0 “Not at all,” to 4 “To a very great extent,” with higher scores representing higher levels of emotional exhaustion. The scale has demonstrated sound psychometric and measurement characteristics (six items, current sample α = 0.91).

Transformational Leadership

The Multifactor Leadership Questionnaire-5x (Bass and Avolio 1995) was used to assess participants’ perceptions of their supervisor’s leadership behaviors. Providers were asked to report on the extent to which their immediate supervisor engaged in specific behaviors (e.g., spends time teaching and coaching). Each behavior was rated on a 5-point scale ranging from 0 “Not at all,” to 4 “To a very great extent.” Transformational leadership was assessed using the following four subscales: Idealized Influence (eight items, current sample α = 0.85), Inspirational Motivation (four items, current sample α = 0.89), Intellectual Stimulation (four items, current sample α = 0.81), and Individual Consideration (four items, current sample α = 0.85). Overall transformational leadership was calculated as the mean score across all items in these four subscales (20 items, α = 0.95).

Turnover Intention

Turnover intention is defined as the degree to which the respondent intends to leave or stay at their organization. Turnover intention was assessed with five items (e.g., “I am actively looking for a job at another agency”) derived from organizational studies and adapted for use in human service agencies (Knudsen et al. 2003; Walsh et al. 1985). Respondents rated each item on a 5-point scale ranging from 0 “Not at all,” to 4 “To a very great extent.” The scale has good factor structure and validity with factor loadings ranging from 0.82 to 0.88, and excellent reliability (five items; current sample α = 0.89).

Control Variables

The questionnaire also included questions about respondents’ age, gender, mental health care tenure, and caseload size. Mental health experience was the number of years and months the respondent has worked in mental health care. Caseload size reflects a clinician’s self-reported number of active cases at the time of the survey administration.

Procedure

A program manager at each program was contacted and the study was described in detail. Permission was sought to survey service providers who worked directly with youths and families. For participating programs, providers’ survey sessions were scheduled at the program site at a time designated by the program manager. Surveys were administered to groups of providers. The project coordinator or a trained research assistant administered providers’ surveys and was available during the survey session to answer any questions that arose. Surveys averaged approximately 60 minutes in length. Participants received a verbal and written description of the study, and informed consent was obtained before the survey. Participation in the study was voluntary, and all participant responses were confidential. This study was approved by the appropriate institutional review boards (University of California-San Diego, Rady Children’s Hospital, and San Diego County Mental Health Services). The authors of this study report no known conflicts of interest and certify responsibility for this manuscript.

Analyses

Pearson product-moment correlation analyses were first conducted to examine associations of turnover intention with the covariates well as the intercorrelations among the covariates. Next, a moderated regression analysis was conducted to examine the associations of transformational leadership and emotional exhaustion with turnover intention as well as the moderating effect of transformational leadership on the relationship between emotional exhaustion and turnover intention. Because providers were nested within supervisors, resulting in potential dependency of responses within supervisors, multilevel analyses were conducted to control for the effects of the nested data structure (Hedeker et al. 1991; Raudenbush and Bryk 2002). Additionally, clinician age, gender, months working in mental health care, and caseload size were included in the analyses as control variables. Following the recommendations of Kleinbaum et al. (2008), a decision was made to include the control variables in the final model if they accounted for a change of more than 15% in the parameter estimates for the covariate or moderation terms. Analyses were conducted in SPSS 18.0 using the mixed model function to account for the nested data structure. Results are presented using unstandardized parameter estimates.

Results

Descriptive Statistics

The mean age for participants was 36.0 (SD = 10.6) years and the majority of respondents were female (81.4%). The racial/ethnic distribution was 51.7% Caucasian, 7.8% African American, 23.9% Hispanic, 4.2% Asian American, 0.3% Native American, and 12.2% Other. Participants’ highest level of education was as follows: 5.9% Ph.D./M.D. or equivalent, 63.9% master’s degree, 6.7% graduate work but no degree, 13.4% bachelor’s degree, 2.3% associate’s degree, 3.9% some college but no degree, 1.0% high school diploma, and 0.3% less than a high school diploma.

Participants worked in the mental health services field for a mean of 7.9 years (SD = 7.4), in child and/or adolescent mental health services for a mean of 6.9 years (SD = 7.2), and in their present agency for 3.0 years (SD = 4.1). The average caseload size for participants was 14.8 clients (SD = 13.32).

The average emotional exhaustion score was 1.23 (SD = 1.0), on a 0–4 scale, with higher scores signifying higher levels of emotional exhaustion. The average transformational leadership score was 2.40 (SD = 0.86), with higher scores signifying higher levels of transformational leadership behaviors, and the average level of turnover intention was 1.47 (SD = 1.04), with higher scores indicating greater intentions to leave one’s current position.

Table 1 presents the intercorrelations among all study variables. As expected, emotional exhaustion was positively correlated with turnover intention. Additionally, consistent with our hypotheses, transformational leadership was negatively correlated with both emotional exhaustion and turnover intention. Of the hypothesized control variables, only age and months in mental health were significantly related to turnover intention with younger providers and providers with less time working in the field reporting greater turnover intention.

Table 1 Intercorrelations of study variables
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Regression Analyses

When examining the combined effects of the selected control variables entered into the multilevel regression equation simultaneously with the independent variables and moderator term, the observed change in coefficients was less than 15%. Additionally, none of the control variables were significant when entered with the other covariates in the model. Therefore, we present the moderated regression model and coefficient terms without including the effects of these non-significant control variables.

Table 2 presents the results of the moderated multilevel regression analyses. As predicted, emotional exhaustion was significantly associated with turnover intention. However, when controlling for the effects of emotional exhaustion, the relationship between transformational leadership and turnover intention was attenuated such that it was no longer significant in the model. As hypothesized, a significant moderator relationship existed, whereby higher levels of transformational leadership reduced the positive associations between emotional exhaustion and turnover intention. As shown in Fig. 1, we employed a mean split on the transformational leadership variable to categorize supervisors into those with high and low transformational leadership. We then used the unstandardized regression equations to display the relationships between emotional exhaustion and turnover intention as moderated by leadership.

Table 2 Multilevel moderated regression of emotional exhaustion and transformational leadership on turnover intention
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Fig. 1
figure 1

Moderation effect of transformational leadership on the relationship between provider’s emotional exhaustion and turnover intention

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Discussion

Although both emotional exhaustion and turnover intention have been identified as significant issues affecting mental health providers and organizations (Aarons et al. 2009a, b; Glisson et al. 2006; van Daalen et al. 2009), research suggesting ways to reduce the relationship between the emotional exhaustion and turnover intention have been rare. This study examined the effects of emotional exhaustion and transformational leadership on turnover intention in a sample of mental health care providers. As hypothesized, emotional exhaustion was positively related to turnover intention and transformational leadership was negatively related to both emotional exhaustion and turnover intention. However, in multivariate analyses only emotional exhaustion was related to turnover intention. Additionally, as hypothesized, transformational leadership moderated the association between emotional exhaustion and turnover intention, with higher transformational leadership reducing the strength of the positive association. This finding indicates that having a stronger transformational leader may help to buffer the effects of emotional exhaustion on turnover intention.

Leadership is a key organizational issue both in times of stable organizational operations and in times of organizational change (Aarons and Sommerfeld 2011). While leadership development programs are readily available, there has been little attempt to validate many such trainings. By exploring transformational leadership as exemplified in the full range model, we examined an “evidence-based” approach to leadership. Indeed, the full range model is the most thoroughly researched approach to leadership with validity evidence in multiple types of industries and organizations, and across national and international contexts (Antonakis et al. 2003; Lowe et al. 1996).

Some limitations of the present study should be noted. First, only cross-sectional data was collected, therefore causality cannot be determined. Second, all variables were based on respondent self-reports, and therefore common method variance may have influenced the results presented here. However, the scales and measures were spread throughout a longer survey and the leadership measure assesses specific observable behaviors. Finally, this study took place in one county mental health service system and results may not generalize to other service sectors or workers. However, these results may inform studies in other sectors and service systems, as workforce issues that are common across service sectors and types.

In community mental health services, training supervisors in transformational leadership may help to engage staff and reduce emotional exhaustion and burnout. Each dimension of transformational leadership can be applied specifically to mental health services. For example, intellectual stimulation may improve the ability of staff to problem solve around the variety of problems presented by clients, while inspirational motivation may build on providers’ desire to help clients to create an environment in which team members support one another in their pursuit of shared goals. Leadership training targeted to the development of strategic climates is another potential area for both research and applied work in mental health services. Strategic climates are those that focus on a particular issue or strategy (Schneider et al. 2005). For example, leaders could be trained to create a favorable climate for evidence-based practice implementation (Aarons et al. 2011).

Emotional exhaustion and turnover are persistent problems for mental health agencies and systems, contributing to higher costs and diminishing service quality. However, there is cause for optimism that these issues can be addressed. The results of this study suggest that investing in developing supervisor transformational leadership knowledge, skills, abilities, and behaviors could improve provider emotional exhaustion and ultimately reduce turnover. Transformational leadership skills can be learned, and training programs focused on transformational leadership have been shown to improve job performance and organizational commitment of those supervised by trainees (Barling et al. 1996; Dvir et al. 2002). Therefore, leadership is a promising area for intervention and one that can improve the lives of supervisors, providers, and ultimately improve the quality and outcomes of mental health services (Glisson and James 2002; Glisson et al. 2008; Knudsen et al. 2003; Stordeur et al. 2001).