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SPIRITUAL AND EMOTIONAL SUPPORT

Effect of spiritual intelligence, emotional intelligence, psychological ownership and burnout on caring behaviour of nurses: a cross-sectional study Devinder Kaur, Murali Sambasivan and Naresh Kumar

Aims and objectives. To propose a model of prediction of caring behaviour among nurses that includes spiritual intelligence, emotional intelligence, psychological ownership and burnout. Background. Caring behaviour of nurses contributes to the patients’ satisfaction, well-being and subsequently to the performance of the healthcare organisations. This behaviour is influenced by physiological, psychological, sociocultural, developmental and spiritual factors. Design. A cross-sectional survey was used, and data were analysed using descriptive statistics and structural equation modelling. Methods. Data were collected between July–August 2011. A sample of 550 nurses in practice from seven public hospitals in and around Kuala Lumpur (Malaysia) completed the questionnaire that captured five constructs. Besides nurses, 348 patients from seven hospitals participated in the study and recorded their overall satisfaction with the hospital and the services provided by the nurses. Data were analysed using structural equation modelling (SEM). Results. The key findings are: (1) spiritual intelligence influences emotional intelligence and psychological ownership, (2) emotional intelligence influences psychological ownership, burnout and caring behaviour of nurses, (3) psychological ownership influences burnout and caring behaviour of nurses, (4) burnout influences caring behaviour of nurses, (5) psychological ownership mediates the relationship between spiritual intelligence and caring behaviour and between emotional intelligence and caring behaviour of nurses and (6) burnout mediates the relationship between spiritual intelligence and caring behaviour and between psychological ownership and caring behaviour of nurses. Conclusions. Identifying the factors that affect caring behaviour of nurses is critical to improving the quality of patient care. Spiritual intelligence, emotional intelligence, psychological ownership and burnout of nurses play a significant role in effecting caring behaviour of nurses. Relevance to clinical practice. Healthcare providers must consider the relationships between these factors in their continuing care and incorporation of these in the nursing curricula and training. Key words: burnout, caring behaviour, emotional intelligence, nurses, psychological ownership, public hospital, spiritual intelligence Accepted for publication: 3 April 2013

Authors: Devinder Kaur, PhD, Senior Lecturer, Asia Pacific University of Technology & Innovation (A.P.U), Bukit Jalil; Murali Sambasivan, PhD, Professor, Graduate School of Management, Universiti Putra Malaysia, Serdang, Global Entrepreneurship Research and Innovation Centre (GERIC), Universiti Malaysia Kelantan, Putrajaya and Taylor’s Business School, Taylor’s University, Subang Jaya; Naresh Kumar, PhD, Associate Professor,

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Graduate School of Management, Universiti Putra Malaysia, Serdang and Global Entrepreneurship Research and Innovation Centre (GERIC), Universiti Malaysia Kelantan, Putrajaya, Malaysia. Correspondence: Murali Sambasivan, Professor, GERIC, UMK, Lot 2B, Second Floor, Jalan 2/1 Diplomatik, Presint Diplomatik, 62050 Putrajaya, Malaysia. Telephone: +60 12 9350065. E-mail: [email protected]

© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 22, 3192–3202, doi: 10.1111/jocn.12386

Spiritual and emotional support

Introduction Quality health care is of crucial importance to healthcare consumers, and healthcare providers across the world are assessed based on their standards of care and service excellence (Anthony et al. 2004, Ford et al. 2006). Previous literature has pointed out that nurse caring behaviour contributes to healthcare organisations in three distinct ways: (1) increasing the satisfaction level of patients, (2) enhancing patients’ well-being and (3) improving financial performance (Tzeng et al. 2002, Al-Mailan 2005). However, based on the review of literature, the factors effecting caring behaviour have not been identified and investigated adequately (Leiter et al. 1998, Rego et al. 2010), and this research addresses four such factors (constructs): spiritual intelligence (SI), emotional intelligence (EI), psychological ownership (PO) and burnout (BO). Of these, effects of SI and PO on caring behaviour are new in the nursing literature. In this study, caring behaviour refers to physical and affective aspect of care shown by nurses that provides comfort, both physical and emotional, to the patients (Rego et al. 2010). The following four paragraphs outline the importance of the four constructs (SI, EI, PO and BO) on the caring behaviour of nurses. Pellebon and Anderson (1999) have asserted that spirituality has the ‘most notable impact on an individual’s attitudes, behaviors and decision-making process’ (p. 229). The concept of spirituality is important and forms the basis of nursing actions (Van Leeuwen & Cusveller 2004). Therefore, including spirituality into nursing care leads to superior performance and excellent quality care to patients (Donley 1991). Very few empirical studies have provided supporting evidence linking spirituality and caring behaviour of nurses, and to our knowledge, there are no empirical studies linking SI and caring behaviour of nurses. Managing emotions is an important skill for nurses (Freshwater & Stickley 2004, McQueen 2004). Emotional intelligence (EI) facilitates the management of emotion in intrapersonal and interpersonal dynamics that enables the ability to think and function in a constructive and rational way (Akerjordet & Severinsson 2007). Sumner and Townsend-Rocchiccioli (2003) have asserted that an effective management of one’s own and others’ emotions is crucial to providing quality patient care. Therefore, EI can have a positive impact on the caring behaviour of nurses. Despite the theoretical support, empirical studies that link the concept of EI and caring behaviour are rare (Akerjordet & Severinsson 2007, Kooker et al. 2007, Rego et al. 2010). © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 22, 3192–3202

Factors affecting caring behaviour of nurses

Stress is an inherent and widely accepted part of the nursing profession, and a prolonged exposure to stress leads to burnout (BO) which in turn affects the performance of nurses. BO has been linked to decreased motivation, reduced effectiveness and increased negative attitudes and behaviour at work (Maslach et al. 2001, Laschinger & Leiter 2006). However, empirical research that examines the link between BO and caring behaviour is limited (Leiter et al. 1998). Literature provides evidence that individuals may develop feelings of ownership towards their organisation, jobs, inventions, work space and work tools (Mayhew et al. 2007). Beliefs of ownership can have a positive effect on employee’s work attitudes and work behaviours (Mayhew et al. 2007, Md-Sidin et al. 2010). However, no empirical research so far has linked the concept of PO and caring behaviour of nurses.

Background Framework of this research is influenced mainly by the Neuman’s System Model (Neuman 1995). Neuman’s System Model describes the wellness of the client or the client system in relation to environmental stress and reaction to stress (Neuman 1995). In other words, the Neuman’s System Model provides a comprehensive explanation of an individual’s adaptation to environmental stressors. She has emphasised the combination of spirit, mind and body in adapting to the environment to retain, attain and maintain wellness and has identified five variables that affect the performance of nurses: physiological, psychological, sociocultural, developmental and spiritual. In this study, the nurse is identified as the client system and further description of the client system identifies the basic structure or core as the hospital staff nurses’ caring behaviour. Caring is influenced by the ability of the hospital nurses to provide quality care to patients while managing stress. The basic core may be repeatedly bombarded by stressors at work and the environment. The stressors may try to break through the lines of defence and resistance and cause damage to the core that is the nurses’ caring behaviours. The term ‘defence’ in this context includes usual wellness of nurses and external protection from individual, family, group or community. The term ‘resistance’ refers to protective mechanisms that can help nurses return to usual wellness. The lines of resistance and defence must protect the nurse, and the quality of the nurses’ caring behaviour will depend on the strength of the lines of defence and resistance. For example, if the lines of resistance in nurses are

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inadequate, burnout may occur and further affect the core resulting in decrease in the level of caring behaviours among nurses. Neuman (1995) has proposed that the physiological, psychological, sociocultural, developmental and spiritual variables determine the strength of protection provided by the lines of defence and resistance. Thus, when considering the interaction of burnout with the ability to give conscientious care, an individual may rely on all or any of the five variables to strengthen the flexible and normal line of defence. In doing so, the nurse will be able to prevent the penetration of both the lines of defence and protect the basic core. The interaction between these five variables can have a direct impact on the caring behaviour of nurses (Deshpande & Joseph 2009). This study addresses the effect of SI (spiritual), EI (psychological), BO (physiological) and PO (psychological) on the caring behaviour of nurses. The conceptual framework used in this study is given in Fig. 1.

EI and caring behaviour Nurses who recognise their own and patients’ emotions are more likely to manage them and show better care towards patients (Kerfoot 1996, McQueen 2004). According to Rego et al. (2010), caring is the essence of nursing and nurses must (1) be respectful and responsive to individual patient preferences, values and needs and (2) provide patients with emotional support (p. 1419). To date, only a study by Rego et al. (2010) has empirically validated the relationship between EI and caring behaviour of nurses. Based on these arguments, we hypothesise: H1: There is a positive relationship between EI and nurse caring behaviours.

Emotional (EI)

(-ve)

Burnout (BO)

(-ve)

(+ve) (+ve) (-ve) (+ve) Spiritual (SI)

(+ve)

(+ve)

(+ve)

Figure 1 A theoretical framework (with hypothesised relationships) to study caring behaviour of nurses. SI, spiritual intelligence; EI, emotional intelligence; PO, psychological ownership; BO, burnout; CB, caring behaviour.

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Spirituality and nursing have been linked since the origins of the profession. Holistic care is the balance between body, mind and spirit, and therefore, spiritual dimension plays an important role in nursing (Neuman 1995, Narayanasamy 2006). Many authors have recommended that spirituality be included in the education and training of nurses to provide holistic nursing care (Narayansamy & Owens 2001, Yang & Mao 2007). Spirituality and SI are strongly linked (Emmons 2000). Based on this link, we hypothesise: H2: There is a positive relationship between SI and nurse caring behaviours.

PO and caring behaviour Pierce et al. (2003) have asserted that psychological ownership promotes a sense of responsibility that includes the feelings of being protective and compassionate for the target (target refers to the organisation and/or job). In short, PO creates a ‘sense of responsibility that influences behavior’ (Van Dyne & Pierce 2004, p. 445). Previous research has suggested that employees with high PO are more likely to display positive in-role (refers to performance in the job) (Md-Sidin et al. 2010, Bernhard & O’Driscoll 2011) and extra-role behaviours (refers to citizenship behaviours) (Pierce et al. 2001, Mayhew et al. 2007, Bernhard & O’Driscoll 2011). Based on the above arguments, we posit: H3: There is a positive relationship between PO and nurse caring behaviours.

BO and caring behaviour An individual suffering from BO begins to distance from clients because he/she has exhausted useful coping mechanisms. Maslach (1979) describes distancing as unhealthy for both client and caregiver, because it negatively influences caring behaviour. Based on the above arguments, we postulate: H4: There is a negative relationship between BO and nurse caring behaviours.

Caring (CB)

(-ve) Ownership (PO)

SI and caring behaviour

SI and EI Theoretical propositions have pointed out SI as core ability, a general factor that penetrates into and guides other abilities (Fry 2003, Ronel & Gan 2008). Specifically, some authors have asserted that SI influences EI (Zohar & Marshall 2000, Hosseini et al. 2010). Based on the above arguments, we hypothesise:

© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 22, 3192–3202


H5: There is a positive relationship between SI and EI of nurses.

SI and PO


H9: There is a negative relationship between EI and BO of nurses.

PO and BO

Control has been suggested to be a critical determinant of feelings of ownership (Furby 1978). Theoretical propositions and empirical research have positively linked spirituality to internal locus of control (Jackson & Coursey 1988, Fiori et al. 2004). Psychological ownership is similar to having an internal locus of control because it represents an internally based drive to effect circumstances. Based on the above arguments, we postulate: H6: There is a positive relationship between SI and PO of nurses.

As people become emotionally depleted, they cope by cutting back on their involvement with others. This depersonalisation effect leads to various negative attitude and behaviours. According to researchers, PO leads to positive work attitudes and behaviours (Van Dyne & Pierce 2004, Mayhew et al. 2007). If nurses develop high levels of PO towards their jobs, depersonalisation effect can be reduced to a great extent and this in turn can reduce the BO of nurses. Based on these arguments, we postulate: H10: There is a negative relationship between PO and BO of nurses.

SI and BO

Mediating role of BO

Researchers have argued that higher levels of spirituality result in lower levels of BO among individuals (MacDonald & Friedman 2002). Few studies have shown that dimensions of spirituality can buffer the negative effects of BO (Alexander et al. 1989, King & DeCicco 2009). Based on the above arguments, we posit: H7: There is a negative relationship between SI and BO of nurses.

There are only a few studies that have examined the mediating role of BO between individual differences and work outcomes. Huang et al. (2010) have proposed that BO mediates the relationship between emotional intelligence and work performance. In the earlier sections, we have espoused the following relationships: between SI, EI, PO and BO; between BO and caring behaviour of nurses; and between SI, EI, PO and caring behaviour of nurses. Based on these arguments, we posit: H11a: BO mediates the relationship between SI and nurse caring behaviours. H11b: BO mediates the relationship between EI and nurse caring behaviours. H11c: BO mediates the relationship between PO and nurse caring behaviours.

EI and PO Theoretical propositions and empirical research have positively linked EI to internal locus of control (Broedling 1975, Singh 2006). Thus, high levels of EI enable an employee to have personal control. Emotional management refers to the ability to regulate and control emotions and behaviours according to situational appropriateness. Therefore, managing own emotions enables an employee to have personal control, which can be regarded as a proxy for control over the employee’s work environment and contribute to the feelings of ownership. One of the main routes to PO is perceived control as it satisfies the human motive of efficacy (Pierce et al. 2004). Therefore, we hypothesise: H8: There is a positive relationship between EI and PO of nurses.

EI and BO Several researchers have studied the relationship between EI and BO (Chan 2006, Brackett et al. 2010). The development of BO syndrome may depend on the interpretation of emotional information. Therefore, we postulate: © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 22, 3192–3202

Mediating role of PO There are no studies linking PO and nurses. In earlier sections, we have espoused the following relationships: between SI, EI and PO; between PO and caring behaviour of nurses; and between SI, EI and caring behaviour of nurses. Based on these arguments, we posit: H12a: PO mediates the relationship between SI and nurse caring behaviours. H12b: PO mediates the relationship between EI and nurse caring behaviours.

Methods The aim of the study is to propose a model of prediction of caring behaviour among nurses that includes SI (spiritual

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intelligence), EI (emotional intelligence), PO (psychological ownership) and BO (burnout). A cross-sectional study design was used. A sample of 550 nurses in practice from seven public hospitals in and around Kuala Lumpur (Malaysia) completed the questionnaire that captured five constructs. Besides nurses, 348 patients from seven hospitals participated in the study and recorded their overall satisfaction with the hospital and the services provided by the nurses. The research was conducted between July 2011–August 2011.

Participants The study was conducted in seven large public hospitals in and around the vicinity of Kuala Lumpur, capital of Malaysia. These hospitals have a total capacity of 6194 beds, and 7446 nurses are employed in these hospitals. A sample of 550 nurses was selected at random. The nurses were from the following departments: general surgical, general medical, paediatrics, obstetrics and gynaecology and orthopaedics. Besides nurses, 348 patients from seven hospitals participated in the study and recorded their overall satisfaction with the hospital and the services provided by the nurses. Responses from the patients helped validate the caring behaviour of nurses. The demographic characteristics of the respondents are given Table 1.

Ethical considerations Permission to conduct research in these seven hospitals was obtained from the Ethics and Research Committee of Ministry of Health Malaysia. The permission helped gain access to seven hospitals. The questionnaires were distributed through the chief matron at each hospital. The nurses were given the option to refuse participation. It was made clear that returning the questionnaire after completion was considered as informed consent for participation in the study.

Instrument The questionnaire designed for this study consisted of six sections. The questionnaire items were made available in English and Bahasa Malaysia (BM – national language of Malaysia). The translation was checked by language experts. Section A captured EI, and the scale with 33 items developed by Schutte et al. (1998) [Schutte Self-Report Emotional Intelligence Test (SSEIT)] was adopted in this study. Section B captured SI, and the scale with 24 items developed by King and DeCicco (2009) [Spiritual Intelligence Self-Report Inventory (SISRI)] was adopted in this

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Table 1 Demographic characteristics of the nurses (n = 448) Variable Gender Male Female Age (years) 20–29 30–39 40–49 50–59 Ethnic group Malay Chinese Indian Others Marital status Single Married Divorced Widowed Years of work experience Qualification Certificate Diploma Bachelor’s Master’s Department General medical General surgical Paediatrics O&G Orthopaedic

n

%

10 438

223 9777

195 136 62 55

4353 3036 1384 1227

404 11 27 6

9018 245 603 134

112 333 1 2

2500 7433 022 045

62 110 87 81 29 79

1385 2455 1942 1808 647 1763

51 364 30 3

1138 8125 670 067

117 118 80 68 65

2612 2634 1786 1518 1450

study. Section C captured BO, and the scale with 22 items developed by Maslach et al. (1996) [Maslach Burnout Inventory–Human Service Survey (MBI-HSS)] was adopted in this research. Section D captured PO, and the scale with six items developed by Pierce et al. (2004) was adopted in this research. Section E captured caring behaviours of nurses, and the scale with 24 items developed by Wu et al. (2006) was adopted in this research. Section F captured the demographic data. The patient satisfaction with overall nursing care was measured to validate the findings on the nurses’ own perception of their caring behaviours. This scale contained three items and was adopted from the study by Otani et al. (2010). Written permissions were obtained from all the authors before using their scales. © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 22, 3192–3202



Data analysis Of the total 550 questionnaires sent, 487 were returned (response rate = 885%). Thirty-nine questionnaires were not filled properly, and finally, 448 were deemed usable. Reliabilities and validities of various constructs are given in Table 2. Descriptive statistics such as mean and standard deviation of constructs and correlation between constructs were computed using SPSS, version 18, and the values are given in Table 3. The confirmatory factor analysis (CFA) and testing of hypotheses were performed using structural equation modelling (SEM) software, LISREL, student version 8.52 (Scientific Software International, Inc., Skokie, IL, USA). Mediation analyses of BO and PO were performed based on the procedure suggested by Baron and Kenny (1986) and Mathieu and Taylor (2006).

with the help of language experts from Universiti Putra Malaysia. The translated version was then compared with the original version to ensure validity of the instrument. An internal consistency reliability test was performed on the five constructs using Cronbach’s alpha values, and the values were between 075–092. Besides, validity test was performed using confirmatory factor analysis (CFA). The convergent and discriminant validities were checked using the guidelines prescribed by Hair et al. (2009): (1) composite reliability (CR) of all constructs was > 07 except burnout, (2) average variance extracted (AVE) of all constructs was > 05 and (3) AVE of each construct was greater than the squared correlation of that construct with other constructs.

Results Reliability and validity The questionnaire was prepared in English and Bahasa Malaysia (BM). The BM version was translated to English

Based on the mean values of the constructs, characteristics of Malaysian nurses in public hospitals are: majority of nurses are women (about 98%), average age of nurses is 345 years,

Table 2 Results of reliability and confirmatory factor analysis (CFA)

Variable

No. of items/ dimensions

Cronbach’s alpha (n = 448)

Emotional intelligence

33/4

089

Spiritual intelligence

24/4

092

Burnout

22/3

075

6/1

088

24/4

092

Psychological ownership Caring behaviours

Validity (CFA)* v2 = 060 (p-value = 074), RMSEA = 0015, RMR = 0015, GFI = 099, NFI = 099, CFI = 099 v2 = 117 (p-value = 028), RMSEA = 0019, RMR = 00051, GFI = 099, NFI = 099, CFI = 099 v2 = 00058 (p-value = 094), RMSEA = 0019, RMR = 00051, GFI = 099, NFI = 099, CFI = 099 v2 = 112 (p-value = 0772), RMSEA = 0005, RMR = 00062, GFI = 099, NFI = 099, CFI = 099 v2 = 811 (p-value = 0017), RMSEA = 0013, RMR = 0013, GFI = 098, NFI = 098, CFI = 098

v2, chi-square value; RMSEA, root mean square error approximation (must be < 008); RMR, root mean square residual (must be < 008); GFI, goodness-of-fit index (must be > 09); NFI, normed fit index (must be > 09); CFI, comparative fit index (must be > 09). *CFA was performed using LISREL 8.52 student version. Analysis was performed at the construct-dimension level.

Table 3 Mean, standard deviation and correlation between constructs Variable

Mean

SD

EI

SI

BO

PO

CB

CR

AVE

EI SI BO PO CB

385 352 215 424 424

006 010 009 009 011

100 0525** 0251** 0289** 0315**

028* 100 0179** 0236** 0243**

0063 0032 100 0288** 0333**

0084 0056 0083 100 0357**

01 0059 011 0127 100

084 091 062 079 091

057 072 052 055 072

EI, emotional intelligence; SI, spiritual intelligence; BO, burnout; PO, psychological ownership; CB, caring behaviour; CR, composite reliability; AVE, average variance extracted. *Values above the diagonal are squared correlations. **Significant at 001 level.


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average work experience is 10 years, nurses have moderate SI (mean = 352) and EI scores (mean = 385), low BO score (mean = 215), high PO (mean = 424) and caring behaviour scores (mean = 424). The measure on patient satisfaction indicates: (1) 90% of patients are satisfied with the care provided by the nurses, (2) 80% are willing to return if needed and (3) 78% are willing to recommend public hospitals to others. The responses from the patients are in line with the nurses’ own perception of their caring behaviour. The significant relationships between various constructs are shown in Fig. 2. Based on the results, many interesting findings are in order. First, SI has a strong positive relationship with EI (r = 053, p = 0000). The result of this study is consistent with the theoretical proposition that SI is a general factor of intelligence underlying any other factor of intelligence and therefore has the capability to influence EI (Zohar & Marshall 2000, Ronel & Gan 2008). Second, individuals (nurses) with higher levels of SI tend to have higher levels of PO towards their jobs (r = 012, p = 0016). According to Pierce and Rodgers (2004), there are three factors that facilitate the development of PO: (1) personal control over the target, (2) better knowledge about the target and (3) investment of self to the target. SI through its four components (critical existential thinking, personal meaning production, transcendental awareness and conscious state expansion) (King & DeCicco 2009) enable individuals to have control, develop intimate contact and invest self to the object or target (Fiori et al. 2004). In this study, the target or object is the job of nursing. Third,

Mediator Emotional

Mediator Burnout (BO)

–0·18(0·000) 0·19(0·000)

(EI)

0·53(0·000)

–0·22(0·000)

0·23(0·000) –0·24(0·000)

Caring (CB)

Spiritual 0·12(0·016)

Ownership (PO)

0·24(0·000)

(SI) Mediator Figure 2 Factors affecting caring behaviour of nurses. All relationships are significant – structural model run at the construct level; numbers given in the parentheses are p-values. SI, spiritual intelligence; EI, emotional intelligence; PO, psychological ownership; BO, burnout; CB, caring behaviour. Model fit indices: v2 = 231 (p-value = 031), RMSEA = 0019, RMR = 0015, CFI = 099, GFI = 099, NFI = 099 (Analysis software – LISREL, 8.52 student version).

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individuals (nurses) with higher levels of EI have higher levels of PO towards their jobs (r = 023, p = 0000). EI through its four components (perception of emotion, managing own emotion, managing others’ emotion and utilisation of emotion) (Ciarrochi et al. 2001) enables nurses to have control over their jobs (Singh 2006). Fourth, nurses with high levels of EI exhibit higher levels of caring behaviour (r = 019, p = 0000). The results of this study are consistent with the findings by Rego et al. (2010), and they have studied the effect of EI on the caring behaviour of nurses in Portugal. EI plays an important role in forging successful human relationships (McQueen 2004). Nurses who cannot manage their emotions and understand their patients’ emotions cannot provide high-quality care. Fifth, nurses with higher levels of EI suffer lesser levels of BO (r = 018, p = 0000). Chan (2006) has studied the relationship between EI and BO using a sample of Chinese secondary school teachers in Hong Kong and has found that EI is negatively associated with BO. Our study supports the notion that people-oriented jobs like nursing require high levels of EI to experience low levels of BO. Sixth, nurses with higher levels of PO experience lesser levels of BO (r = 024, p = 0000). Among the different healthcare providers, nurses are considered at high risk of workrelated stress and are particularly susceptible to BO (Piko 2006). Researchers have argued that PO leads to positive work attitudes and behaviours (Van Dyne & Pierce 2004, Mayhew et al. 2007, Md-Sidin et al. 2010), and these can lead to lesser levels of BO through reduction in the levels of emotional exhaustion. Seventh, nurses who experience higher levels of BO exhibit poor caring behaviour (r = 022, p = 0000). There is limited empirical evidence on the effect of BO on caring behaviours of nurses, and the results of our study are consistent with the findings of earlier studies (Leiter et al. 1998). Eighth, nurses with higher levels of PO exhibit better caring behaviour (r = 024, p = 0000). Many previous studies have provided adequate empirical evidence to show that PO influences work-related behaviours (Van Dyne & Pierce 2004, O’Driscoll et al. 2006, Bernhard & O’Driscoll 2011). Even though there are no previous studies that link PO and caring behaviour of nurses, we believe that, from the theoretical foundations of PO, there is enough evidence to support our conclusions. Ninth, PO mediates the relationship between (1) EI and caring behaviour (Sobel’s test: t-value = 334, p-value = 0000) and (2) SI and caring behaviour (Sobel’s test: t-value = 203, p-value = 0043). This result is significant because it explains how PO plays a role in explaining the influence of EI and SI on caring behaviour of nurses. EI and SI of nurses enhance the feeling of influence and con© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 22, 3192–3202


trol over the job. This positive feeling towards the job increases PO. Based on the theoretical underpinnings, PO enhances the caring behaviour of nurses. As indicated earlier, this study is first of its kind in nursing literature to study the relationships between EI, SI, PO and caring behaviour of nurses. Tenth, BO mediates the relationship between EI, PO and caring behaviour. Specifically, BO mediates the relationship between EI and caring behaviour (Sobel’s test: t-value = 301, p-value = 0000) and (2) PO and caring behaviour (Sobel’s test: t-value = 35, p-value = 0000). The mediating effect of BO has been analysed in various studies (Maslach et al. 2001, Leiter & Maslach 2009), and specifically, Huang et al. (2010) have studied the mediating role of BO between EI and work performance of employees in a call centre in China. We argue that EI and PO help reduce the BO of nurses by decreasing their feelings of depersonalisation. This effect in turn improves the caring behaviour of nurses.

Discussion As indicated earlier, a few researchers have pointed out SI as core ability, a general factor that penetrates into and guides other abilities (Fry 2003, Ronel & Gan 2008). Our research has clearly established this fact. Based on the results, key findings are: (1) SI influences EI and PO, (2) EI influences PO, BO and caring behaviour of nurses, (3) PO influences BO and caring behaviour of nurses and (4) BO influences caring behaviour of nurses. What are the implications of these findings? SI is very fundamental to nursing profession. It is important to note that spirituality and religiousness are distinctly different but significantly correlated (Moberg 2005, Yang & Wu 2009). It is plausible for a nonreligious person to have a higher level of SI. SI centres on inner resources of a person, and it manifests in various ways such as positive self-concepts, unselfish giving, higher moral character and personal transcendence (Fehring et al. 1987). Therefore, spiritual well-being of nurses is critical for quality health care. Can spirituality be developed and SI improved? The importance of spirituality in nursing has resulted in the emergence of a body of literature that discusses the role of education in meeting the spiritual needs of first the nurses and then their care recipients (Narayanasamy 2006, Baldacchino 2008). The curriculum designed in training and educating nurses must include spirituality. Baldacchino (2008) suggests using self-reflection and case studies in nursing education to enable nursing students to link spirituality and the practice of care. Narayanasamy (2006) has developed a model for spiritual care education and training of nurses. © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 22, 3192–3202


Our research has revealed the two-stage process by which SI may affect nurses’ caring behaviours. First, SI by virtue of its role as an encompassing guide influences EI and PO of nurses. Second, EI and PO, in turn, reduce the effects of BO and influence the caring behaviour of nurses. Research has shown that people with high EI understand their own feelings and the feelings of others, know how to manage themselves and deal successfully with others and respond effectively to work demands (Dulewicz & Higgs 2003). Akerjordet and Severinsson (2007) have asserted that EI has significant implications on nurses’ quality of work in health care. The results of our study validate this assertion. EI, in addition to improving the caring behaviour, helps nurses reduce the effects of BO and increase their feelings of ownership (PO) towards their jobs. According to Freshwater and Stickley (2004), nursing education that fails to acknowledge the value of emotions fails to inform students on the importance of human relations and undermines the core skill of nursing practice. Thus, EI needs to be effectively integrated in the nursing curricula. The concept of PO in nursing literature is fairly new. Many studies have established links between PO and work environment factors such as autonomy, participation in decision-making, technology routinisation at work, leadership styles and perceptions of justice (O’Driscoll et al. 2006, Bernhard & O’Driscoll 2011, Sieger et al. 2011). Managers of hospitals must ensure that an environment conducive for nurses to experience the feelings of ownership is provided. For example, the hospital authorities can provide higher autonomy to nurses and allow them to participate in making decisions that affect them. The feelings of ownership towards their jobs help nurses reduce the effects of BO and improve their caring behaviours. This study has a few implications to the theory and practice of nursing. First, the importance of role of SI in nursing literature has been revealed. Specifically, the fundamental question answered in this study is: As an antecedent, how does SI affect the caring behaviour of nurses? Second, this study has revealed the process by which SI affects the caring behaviour. Specifically, the roles of EI and PO have been explicated. Third, through this study, we have introduced PO as a valid and viable construct into the nursing literature. Fourth, much of the literature related to EI still exists outside nursing, and recently, EI research is gaining momentum within the nursing arena (Freshwater & Stickley 2004, Kooker et al. 2007). In this research, we have expanded the role of EI by studying its effect on PO and BO. Fifth, the mediating roles of BO and PO between SI, EI and caring behaviour have been explored in this research. Sixth, this study makes recommendations about

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the changes that are needed in the nursing curricula and the work environment. Even though the framework in this study has been validated in the context of Malaysia, we believe that the findings can be applied to any other country. The constructs used in this research (SI, EI, PO, BO and caring behaviour) are not country specific, and they capture the essential ingredients of the nursing profession in any part of the world. For example, a study linking EI and caring behaviour of nurses has been conducted in Portugal (Rego et al. 2010); studies linking spirituality and caring behaviour of nurses have been conducted in the UK and Taiwan (Narayansamy & Owens 2001, Yang & Mao 2007). There are a few limitations of this study. First, the study was conducted in seven large public hospitals in and around Kuala Lumpur, which is the largest city in Malaysia. We did not include private hospitals and other public hospitals in Malaysia, and therefore, the results might not be completely generalisable. Second, we were unable to measure the patients’ perception of nurses’ caring behaviours due to the difficulty in matching each patient with each of the nurses. Therefore, we measured the nurses’ perceptions of their own caring behaviours. However, we conducted a separate survey among the patients admitted in the wards to investigate patient’s satisfaction with the overall nursing care. Third, the data were collected from nurses within five major departments. There might be nurses from other departments that were left out in the study. This research has demonstrated the roles of SI, EI and PO in influencing the caring behaviours of nurses in Malaysia. Specifically, the following effects have been revealed: (1) SI as a key guiding construct, (2) SI’s positive influence on EI and PO, (3) EI’s positive effect on caring behaviour

and PO and EI’s negative effect on BO, (4) PO’s positive effect on caring behaviour and PO’s negative effect on BO and (5) BO’s negative effect on caring behaviour. Future research is required in different countries to validate the results.

Relevance to clinical practice Professional healthcare workers and administrators must pay greater attention to the relationships between the soft factors addressed in this research as these are critical to quality of health care provided by nurses. Nursing curricula and training of nurses must include these factors.

Acknowledgements The authors thank the nurses and patients who participated in the study. The authors also thank the Ministry of Health for giving permission to conduct the study and the researchers who shared their research instruments.

Disclosure The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethical_ 1author.html), as follows: (1) substantial contributions to conception and design of or acquisition of data or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content and (3) final approval of the version to be published.

Conflict of interest None declared.

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