Perspective of Supervision

ORIGINAL PAPER

Transformational Leadership Moderates the Relationship Between Emotional Exhaustion and Turnover Intention Among Community Mental Health Providers

Amy E. Green • Elizabeth A. Miller •

Gregory A. Aarons

Received: 2 June 2011 / Accepted: 17 October 2011 / Published online: 4 November 2011

� Springer Science+Business Media, LLC 2011

Abstract Public sector mental health care providers are

at high risk for burnout and emotional exhaustion which

negatively affect job performance and client satisfaction

with services. Few studies have examined ways to reduce

these associations, but transformational leadership may

have a positive effect. We examine the relationships

between transformational leadership, emotional exhaus-

tion, and turnover intention in a sample of 388 community

mental health providers. Emotional exhaustion was posi-

tively related to turnover intention, and transformational

leadership was negatively related to both emotional

exhaustion and turnover intention. Transformational lead-

ership moderated the relationship between emotional

exhaustion and turnover intention, indicating that having a

transformational leader may buffer the effects of providers’

emotional exhaustion on turnover intention. Investing in

transformational leadership development for supervisors

could reduce emotional exhaustion and turnover among

public sector mental health providers.

Keywords Emotional exhaustion � Burnout � Turnover � Leadership � Mental health services

A common concern for human service organizations is

burnout caused by the high stress nature of providing ser-

vices to others. Burnout is a stress-related psychological

syndrome comprised of three components, emotional

exhaustion, depersonalization, and personal accomplish-

ment (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, emo-

tional 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 employ-

ees 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 per-

formance, increased absenteeism, and reduced client sat-

isfaction 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

A. E. Green � E. A. Miller � G. A. Aarons (&)

Department of Psychiatry, University of California, 9500 Gilman

Drive (0812), La Jolla, San Diego, CA 92093-0812, USA

e-mail: [email protected]

A. E. Green � E. A. Miller � G. A. Aarons

Child and Adolescent Services Research Center at Rady

Children’s Hospital, San Diego, CA, USA

123

Community Ment Health J (2013) 49:373–379

DOI 10.1007/s10597-011-9463-0

shown to predict future voluntary turnover (Wright and

Cropanzano 1998). Turnover intention refers to the likeli-

hood 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 pre-

dictor 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 pro-

vision and weaker staff-consumer relationships, therefore

negatively affecting the quality and outcomes of services

provided by these organizations and their staff (Albizu-

Garcı́a 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 pro-

gram managers, in particular, transformational leadership

(Aarons et al. 2011; Stordeur et al. 2001). Transforma-

tional 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 crea-

tivity, 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 leader-

ship is negatively associated with both emotional exhaus-

tion (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). Transforma-

tional 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 sup-

port 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 transfor-

mational leadership can lead to measurable behavioral

change (Avolio and Bass 1998; Barling et al. 1996; Kel-

loway 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 intellec-

tual 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 organi-

zational processes and individual differences in mental

health service systems.

The current study examines the relationships between

emotional exhaustion, turnover intention, and transforma-

tional 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 hypothe-

sized that transformational leadership will moderate the

relationship between emotional exhaustion and turn-

over intention. Specifically, as transformational leadership

374 Community Ment Health J (2013) 49:373–379

123

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 fam-

ilies 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 rat-

ings 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 sam-

ple 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 repre-

senting higher levels of emotional exhaustion. The scale has

demonstrated sound psychometric and measurement charac-

teristics (six items, current sample a = 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 a = 0.85), Inspirational

Motivation (four items, current sample a = 0.89), Intel-

lectual Stimulation (four items, current sample a = 0.81),

and Individual Consideration (four items, current sample

a = 0.85). Overall transformational leadership was calcu-

lated as the mean score across all items in these four

subscales (20 items, a = 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 a = 0.89).

Control Variables

The questionnaire also included questions about respon-

dents’ 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 des-

ignated 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 Hos-

pital, 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

Community Ment Health J (2013) 49:373–379 375

123

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 inten-

tion as well as the moderating effect of transformational

leadership on the relationship between emotional exhaus-

tion 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 recom-

mendations 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% asso-

ciate’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 ado-

lescent 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 trans-

formational 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 indi-

cating greater intentions to leave one’s current position.

Table 1 presents the intercorrelations among all study

variables. As expected, emotional exhaustion was posi-

tively 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 vari-

ables, only age and months in mental health were signifi-

cantly related to turnover intention with younger providers

and providers with less time working in the field reporting

greater turnover intention.

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 mod-

erated 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

Table 1 Intercorrelations

of study variables

1 = male, 2 = female

* P \ 0.05, ** P \ 0.01

1 2 3 4 5 6

1. Sex

2. Age -0.08

3. Caseload 0.07 0.04

4. Months working in MH -0.16** 0.63 0.06

5. Emotional exhaustion 0.03 -0.06 0.09 -0.05

6. Transformational leadership -0.09 -0.01 0.06 0.02 -0.30**

7. Turnover intention -0.04 -0.14** 0.02 -0.17** 0.44** -0.28**

376 Community Ment Health J (2013) 49:373–379

123

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 trans-

formational leadership. We then used the unstandardized

regression equations to display the relationships between

emotional exhaustion and turnover intention as moderated

by leadership.

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 turn-

over 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 lead-

ership reducing the strength of the positive association.

This finding indicates that having a stronger transforma-

tional 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 organiza-

tional 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 orga-

nizations, 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 supervi-

sors 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, intel-

lectual stimulation may improve the ability of staff to

problem solve around the variety of problems presented by

clients, while inspirational motivation may build on pro-

viders’ 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 devel-

opment of strategic climates is another potential area for

Table 2 Multilevel moderated regression of emotional exhaustion

and transformational leadership on turnover intention

Variable B SE t

Intercept 1.06 0.28 3.82

Emotional exhaustion 0.65** 0.14 4.65

Transformational leadership -0.04 0.10 -0.38

Emotional exhaustion by transformational

leadership

-0.11* 0.06 -1.97

* P \ 0.05, ** P \ 0.01

Fig. 1 Moderation effect of transformational leadership on the

relationship between provider’s emotional exhaustion and turnover

intention

Community Ment Health J (2013) 49:373–379 377

123

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 prob-

lems 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 lead-

ership have been shown to improve job performance and

organizational commitment of those supervised by trainees

(Barling et al. 1996; Dvir et al. 2002). Therefore, leader-

ship 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).

Acknowledgments This research was supported by National Insti-

tute of Mental Health grants R01MH072961, R21MH082731,

K01MH001695 (PI: Aarons) and P30MH074678 (PI: Landsverk). We

thank the organizations, supervisors, and service providers that par-

ticipated in the study and made this work possible.

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