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Nursing and Health Sciences (2007), 9, 205–211

Research Article

The psychosocial work environment and burnout among


Swedish registered and assistant nurses: The main,
mediating, and moderating role of empowerment
Jacek Hochwälder bsc, msc, phd
Stockholm Centre of Public Health, Stockholm and Mid Sweden University, Östersund, Sweden

Abstract The aim of the present study was to explore: the main effect of empowerment on burnout; empowerment as
a mediator between the work environment and burnout; and empowerment as a moderator of the association
between the work environment and burnout. In order to explore these effects, multiple regression analyses
were performed on questionnaire data from 838 registered nurses and 518 assistant nurses in Sweden. The
analyses showed that: empowerment has a negative association to burnout; empowerment has a mediating
effect between the work environment (especially for control and social support) and burnout; and the
moderating effect of empowerment on the association between the work environment and burnout was weak.
The results suggest that: empowerment explains variation with regard to burnout over and above what can be
explained by established work situation dimensions; the improvement of the work environment is associated
with a higher sense of empowerment which, in turn, is related to lower degrees of burnout; and individual and
group differences should be considered in workplace health promotion.

Key words burnout, empowerment, nurses, work environment.

INTRODUCTION association between empowerment and ill health (Waller-


stein, 1992). This assertion has been confirmed by a number
It is well-known that a poor work environment can result in
of studies that have observed a negative association between
burnout (e.g. McGrath et al., 2003). An important task for
empowerment and burnout (e.g. Laschinger et al., 2003;
researchers is to find the variables that might protect against
Hochwälder & Bergsten-Brucefors, 2005). A second theoreti-
burnout. Empowerment is a relatively new variable waiting
cal assertion is that empowerment mediates the effects of the
to be tested in the battle against burnout (Lee & Koh, 2001).
work environment on behavioral outcomes or, in other
One of the most established definitions of empowerment
words, that various work environment aspects affect various
has been proposed by Spreitzer (1997). Spreitzer focuses on
behavioral outcomes to some extent via empowerment
psychological empowerment at the workplace, which she
(Spreitzer, 1997). This assertion has received confirmation in
defines as a four-dimensional concept consisting of meaning
a study by Laschinger et al. (2003), who found that a good
(a fit between the requirements of the job tasks and the
work environment results in a higher sense of empowerment
subject’s own values), competence (the subject’s belief that
which, in turn, contributes to preventing burnout. A third
he or she possesses the skills and abilities necessary to
theoretical assertion is that empowerment can moderate the
perform a job or task well), self-determination (the subject’s
effects of various work environment variables on various
feeling of having control over his or her own work), and
behavioral outcomes or, in other words, that the effect of a
impact (the belief that the subject has a significant influence
given work environment variable on a given behavior
over strategic, administrative, or operational outcomes at
outcome might depend on the level of empowerment. No
work). The four dimensions can be used as four separate
study could be located that explored the role of empower-
indicators of empowerment or combined into a single overall
ment as a moderator on the association between the work
indicator of empowerment (Spreitzer, 1995a).
environment and burnout.
A general theoretical assertion is that empowerment has a
The aim of the present study was to explore, for registered
main effect on ill-health, which manifests itself in a negative
nurses and assistant nurses separately because of differences
with regard to a number of fundamental variables (e.g. edu-
cation, work tasks, and wages): (i) the main effect of empow-
Correspondence address: Jacek Hochwälder, Unit of Mental Health, Stockholm
erment on burnout; (ii) empowerment as a mediator between
Centre of Public Health, PO Box 175 33, SE-118 91 Stockholm, Sweden. Email:
jacek.hochwalder@miun.se the work environment and burnout; and (iii) empower-
Received 9 November 2006; accepted 9 March 2007. ment as a moderator of the association between the work

© 2007 The Author doi: 10.1111/j.1442-2018.2007.00323.x


Journal Compilation © 2007 Blackwell Publishing Asia Pty Ltd.
206 J. Hochwälder

environment and burnout. The nurses were studied with dimensions: meaning, competence, self-determination, and
regard to burnout because burnout has been recognized as impact. The total scale consists of 12 items and each of the
one of the major work-related health problems among four dimensions is measured by three items. Examples of
health-care personnel (e.g. Duquette et al., 1994; McGrath items for each of the four dimensions are as follows: “The
et al., 2003). The work environment was studied in terms of work I do is meaningful to me” (meaning), “I am self-assured
job demands, control, and social support, which constitute about my capabilities to perform my activities” (compe-
the fundamental components of the well-established job tence), “I have considerable opportunity for independence
demand-control-support model (Karasek & Theorell, 1990). and freedom in how I do my job” (self-determination), and
A number of variables that have similarities to empower- “My impact on what happens in my department is large”
ment have been studied in relation to the three work envi- (impact). The response scale was a seven-point Likert scale,
ronment dimensions and to various ill health indicators. For ranging from 1 (strongly disagree) to 7 (strongly agree). In
example, sense of coherence has been studied by Söderfeldt order to make a concise presentation and analysis of the
et al. (2000), locus of control by Rodríguez et al. (2001), and mediating and moderating roles of empowerment, one mean
self-efficacy by Schaubroeck and Merritt (1997). The most score was computed for each participant over the four
essential difference between these variables and empower- dimensions, as in some of Spreitzer’s (1995b) studies. This
ment is that empowerment is more related to the work situ- means that the theoretical minimum value was 1 and the
ation and is easier to affect. maximum value was 7. Higher values indicate higher levels of
experienced empowerment.
Burnout was measured with the Maslach Burnout Inven-
METHOD
tory, developed by Maslach and Jackson (1981; 1986). The
scale consists of three dimensions: emotional exhaustion,
Participants
depersonalization, and personal accomplishment. The total
A total of 1356 nurses participated voluntarily in the present scale consists of 22 items and emotional exhaustion is mea-
study. The participants were recruited from three hospitals sured by nine items, depersonalization is measured by five
and two primary health-care centres in the Stockholm area. items, and personal accomplishment by eight items.
The overall response rate was 67%. Eight-hundred-and- Examples of items for each of the three dimensions are as
thirty-eight of the participants were registered nurses (94.5% follows: “I feel emotionally drained by my work” (emotional
women and 5.5% men, mean age = 42.60 years, and standard exhaustion), “I feel I treat some recipients as if they were
deviation [SD] = 10.35 years) and 518 were assistant nurses impersonal objects” (depersonalization), and “In my work, I
(95.4% women and 4.6% men, mean age = 45.30 years, and deal with emotional problems very calmly” (personal accom-
SD = 10.58 years). plishment). The response scale was a seven-point Likert
scale, ranging from 0 (never) to 6 (every day). As recom-
mended by Maslach (Maslach & Jackson, 1986), a mean score
Questionnaire
was computed for each participant on each of the three
The participants completed a self-rating questionnaire com- dimensions. This means that on each dimension, the theoreti-
posed of 53 questions. The variables and how they were mea- cal minimum was 0 and the theoretical maximum was 6. For
sured are now described. the dimensions, emotional exhaustion and depersonalization,
Gender and age were noted. The subjects marked given greater values indicate higher levels of burnout, whereas for
alternatives to indicate their gender and wrote down their age. the dimension of personal accomplishment, lower values
The psychosocial work environment was measured by a indicate higher levels of burnout.
scale developed by Karasek and Theorell (1990). The scale
measures three dimensions: demand, control, and social
support. The total scale consists of 17 items and demand is Procedure
measured by five items, control is measured by six items, and
The questionnaire, with written instructions accompanied by
social support is measured by six items. Examples of items for
a stamped addressed envelope, was sent to the home address
each of the three dimensions are as follows: “Does your work
of the participants. The data were collected during 21 con-
demand that you work very hard?” (demand), “Does your
secutive days. Where necessary, two reminders were sent
work include you doing some tasks over and over again?”
3 weeks apart. The study was approved by the ethical com-
(control), and “I feel comfortable with my workmates”
mittee of the Karolinska Institute in Stockholm.
(social support). The responses were given on a four-point
Likert scale, ranging from 1 (“No, almost never”; alterna-
tively, “Not at all”) to 4 (“Yes, often”; alternatively, “Very
Analyses
well”). An average value on each dimension was computed
for each respondent. For each of the three dimensions, the All descriptions and analyses were performed using the SPSS
theoretical minimum value was 1 and the theoretical 14.0 program (Norusis, 2006) and separately for registered
maximum value was 4. Higher values indicate higher levels of nurses and assistant nurses. Before performing the regression
demand, control, and social support. analyses, all the variables (except for gender, which was
Empowerment was measured with Spreitzer’s empower- dummy-coded) were z-scored centered in order to avoid
ment scale (Spreitzer, 1995b). The scale consists of four problems with unessential multicollinearity (Cohen et al.,

© 2007 The Author


Journal Compilation © 2007 Blackwell Publishing Asia Pty Ltd.
Empowerment 207

2003). Furthermore, the data were checked for multicol- empowerment were added. A moderating effect is said to
linearity using two measures: the tolerance and the variance exist if: (i) any one of the coefficients for the interaction terms
inflation factor (Kleinbaum et al., 1988). One hierarchical is statistically significant; and (ii) any one of the interaction
linear regressions analysis was performed for each of the terms significantly increases the amount of explained vari-
three burnout dimensions as the criterion. In Step 1 of the ance in the criterion (Albertsen et al., 2001). In order to inter-
analyses, the two control variables, age and gender, were used pret the interactions, plots were made according to the
as predictors because they were assumed to be related to recommendations of Cohen et al. (2003). The values of the
empowerment (Spreitzer, 1995b). In Step 2, the three psycho- predictor variables were chosen three SDs below (z = -3) and
social work environment dimensions were added. In Step 3, three SDs above (z = 3) the mean and the regression lines
empowerment was added. A main effect is said to exist if, were produced by entering these values into the regression
after controlling for the effects of the demographic variables equations.
in Step 1 and the work environment variables in Step 2,
empowerment has in the present step (Step 3) a statistically
RESULTS
significant relationship to a given burnout dimension (Feldt,
1997; Albertsen et al., 2001). A mediating effect is said to exist
Descriptive analyses
if: (i) in the previous step of the analysis (Step 2), a given
work environment variable had a statistically significant rela- Table 1 shows the means, SDs, and Cronbach’s alpha coeffi-
tionship to a given burnout dimension; and (ii) in the present cients. The only statistically significant differences between
step (Step 3), empowerment has a statistically significant the means of the registered nurses and the assistant nurses
relationship to the given burnout dimension and the relation- were observed for the variable of age (t1354 = 2.24, P < 0.05
ship between the given work environment variable and the [two-tailed]) and control (t1354 = 3.99, P < 0.001 [two-tailed]).
burnout dimension diminishes or becomes statistically insig- For both groups, the alpha coefficients for all variables,
nificant (Albertsen et al., 2001; Seibert et al., 2004). Finally, in except for control, were satisfactory (ⱖ 0.70). Table 2 shows
Step 4, three bilinear interactions between each one of the the correlations between the variables. For both groups, it can
three psychosocial work environment dimensions and be noted that, except for the correlation between personal

Table 1. Means (M), standard deviations (SD), and Cronbach’s alphas (a) for all variables for registered nurses and for assistant nurses

Registered nurses Assistant nurses


Variable M SD a M SD a

Emotional exhaustion 1.95 1.11 0.90 1.82 1.14 0.90


Depersonalization 0.93 0.89 0.71 0.81 0.84 0.70
Personal accomplishment 4.82 0.76 0.78 4.60 0.99 0.78
Age 42.60 10.35 NA 45.30 10.58 NA
Gender NA NA NA NA NA NA
Demand 2.69 0.48 0.71 2.62 0.47 0.73
Control 3.02 0.37 0.52 2.88 0.40 0.53
Social support 3.22 0.45 0.83 3.19 0.48 0.85
Empowerment 5.29 0.82 0.86 5.24 0.90 0.87

NA, not applicable.

Table 2. Correlation coefficients for all variables for registered nurses below the diagonal and for assistant nurses above the diagonal

Variable 1 2 3 4 5 6 7 8 9

Emotional exhaustion 1.00 0.54*** -0.12** -0.01 0.00 0.53*** -0.16*** -0.48*** -0.41***
Depersonalization 0.54*** 1.00 -0.13** -0.14*** 0.01 0.19*** -0.20*** -0.22*** -0.31***
Personal accomplishment -0.22*** -0.23*** 1.00 -0.02 0.02 -0.01 0.18*** 0.08* 0.30***
Age -0.04 -0.18*** -0.03 1.00 -0.02 -0.01 0.00 -0.01 0.12**
Gender† -0.05 0.06 0.00 -0.08* 1.00 0.07 0.08 -0.04 0.04
Demand 0.54*** 0.24*** -0.04 -0.01 -0.04 1.00 0.01 -0.40*** -0.22***
Control -0.16*** -0.14*** 0.16*** -0.03 0.12*** -0.02 1.00 0.25*** 0.44***
Social support -0.33*** -0.18*** 0.17*** -0.03 -0.01 -0.30*** 0.24*** 1.00 0.40***
Empowerment -0.40** -0.35*** 0.36*** 0.20*** 0.02 -0.23*** 0.38*** 0.33*** 1.00

*P < 0.05 (two-tailed); **P < 0.01 (two-tailed); ***P < 0.001 (two-tailed). †Women were coded with 0 and men with 1.

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208 J. Hochwälder

Table 3. Results from the hierarchical regression analyses, with emotional exhaustion as the criterion variable

Emotional exhaustion
Registered nurses Assistant nurses
Variable b†step 1 bstep 2 bstep 3 bstep 4 bstep 1 bstep 2 bstep 3 bstep 4

Age -0.05 -0.05 0.01 0.01 -0.01 -0.01 0.02 0.01


Gender‡ -0.05 -0.02 -0.03 -0.02 -0.01 -0.04 -0.03 -0.03
Demand – 0.49*** 0.45*** 0.46*** – 0.41*** 0.39*** 0.38***
Control – -0.11*** -0.02 -0.02 – -0.09** -0.01 0.00
Social support – -0.16*** -0.11*** -0.10*** – -0.29*** -0.23*** -0.23***
Empowerment – – -0.26*** -0.26*** – – -0.23*** -0.23***
Demand ¥ empowerment – – – -0.08** – – – -0.01
Control ¥ empowerment – – – -0.01 – – – -0.04
Social support ¥ empowerment – – – 0.01 – – – 0.02
Model F 1.90 85.53 87.75 60.20 0.06 60.94*** 58.92*** 39.38***
(d.f.) (2, 835) (5, 832)*** (6, 831)*** (9, 828)*** (2, 515) (5, 512) (6, 511) (9, 508)
R2 0.01 0.34 0.39 0.40 0.00 0.37 0.41 0.41
DR2 0.01 0.34*** 0.05*** 0.01* 0.00 0.37*** 0.04*** 0.00

*P < 0.05; **P < 0.01; ***P < 0.001. †b is the standardized regression coefficient; ‡women were coded with 0 and men with 1.

accomplishment and demand, all correlations between the


three burnout dimensions and the three work environment
dimensions, as well as between the three burnout dimensions
and empowerment, were statistically significant and went in 2
the expected directions.
Emotional exhaustion

Regression analyses with emotional exhaustion


as the criterion variable
As can be seen in Table 3, neither age nor gender were sig- 0
nificantly related to emotional exhaustion in the two groups
of nurses. For both groups, demand, control, and social
support were related as expected to emotional exhaustion,
explaining 34%/37%, respectively, of the variance in the cri-
terion variable. It may be noted that for assistant nurses, as
compared to registered nurses, social support had a higher –2
negative association with emotional exhaustion (b = -0.29/ Low High
b = -0.16, respectively). For both groups, the main effect of Demands
empowerment on emotional exhaustion was negative and
statistically significant as expected, accounting for an addi- Figure 1. The interaction between demands and empowerment
tional 5%/4%, respectively, of the variance. For both groups, with regard to emotional exhaustion for registered nurses. ---, low
empowerment had a mediating effect between the three empowerment; ––, high empowerment.
environment variables and emotional exhaustion. As can be
seen in Table 3, the regression coefficients for the three envi-
ronment variables diminished and, for control, were even
Regression analyses with depersonalization as the
insignificant when empowerment was added. Only for regis-
criterion variable
tered nurses was one statistically significant moderator effect
of empowerment on the association between the environ- As can be seen in Table 4, in the first step, only age was
ment variables and emotional exhaustion observed, account- significantly related to depersonalization in the two groups,
ing for only an additional 1% of the variance. As can be seen explaining 3%/2%, respectively, of the variance in the crite-
from Figure 1, registered nurses with high empowerment rion. For both groups, demand, control, and social support
were less emotionally exhausted than those with low empow- were related as expected to depersonalization, explaining an
erment and an increase in demands was related to a some- additional 9%/9%, respectively, of the variance. It may be
what lower increase in emotional exhaustion in registered noted that for registered nurses, as compared to assistant
nurses with high empowerment as compared to those with nurses, demand had a somewhat higher positive association
low empowerment. with depersonalization (b = 0.22/b = 0.14, respectively). For

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Journal Compilation © 2007 Blackwell Publishing Asia Pty Ltd.
Empowerment 209

Table 4. Results from the hierarchical regression analyses, with depersonalization as the criterion variable

Depersonalization
Registered nurses Assistant nurses
Variable b†step 1 bstep 2 bstep 3 bstep 4 bstep 1 bstep 2 bstep 3 bstep 4

Age -0.17*** -0.18*** -0.12*** -0.12*** -0.14*** -0.14*** -0.12** -0.12**


Gender‡ 0.04 0.06* 0.06* 0.06* 0.01 0.01 0.01 0.01
Demand – 0.22*** 0.18*** 0.18*** – 0.14** 0.11* 0.10*
Control – -0.13*** -0.04 -0.04 – -0.17*** -0.09 -0.08
Social support – -0.08* -0.03 -0.03 – -0.12** -0.07 -0.08
Empowerment – – -0.26*** -0.26*** – – -0.21*** -0.21***
Demand ¥ empowerment – – – -0.06 – – – -0.01
Control ¥ empowerment – – – 0.02 – – – -0.10*
Social support ¥ empowerment – – – 0.01 – – – 0.06
Model F 14.30*** 22.30*** 28.46*** 19.54*** 5.56 12.07 13.42 9.58
(d.f.) (2, 835) (5, 832) (6, 831) (9, 828) (2, 515) (5, 512) (6, 511) (9, 508)
R2 0.03 0.12 0.17 0.18 0.02 0.11 0.14 0.15
DR2 0.03*** 0.09*** 0.05*** 0.01 0.02** 0.09*** 0.03*** 0.01

*P < 0.05; **P < 0.01; ***P < 0.001. †b is the standardized regression coefficient; ‡women were coded with 0 and men with 1.

both groups, the main effect of empowerment on deperson- 2


alization was negative and statistically significant as
expected, accounting for an additional 5%/3%, respectively,
of the variance. For both groups, empowerment had a medi-
ating effect between the three environment variables and 1
depersonalization. As can be seen in Table 4, the regression
Depersonalization

coefficients for the three environment variables diminished


and, for control and social support, even became insignificant
when empowerment was added. Only for assistant nurses was 0
one moderator effect of empowerment on the association
between the environment variables and depersonalization
observed. As can be seen from Figure 2, for assistant nurses
–1
with high empowerment, an increase in control resulted
in less depersonalization while for assistant nurses with
low empowerment, an increase in control resulted in more
depersonalization. –2

Low High
Regression analyses with personal accomplishment as Control
the criterion variable
Figure 2. The interaction between control and empowerment with
As can be seen in Table 5, in the first step, neither age nor regard to depersonalization for assistant nurses. ---, low empower-
gender was significantly related to depersonalization in the ment; ––, high empowerment.
two groups. For registered nurses, demand, control, and
social support were related as expected to personal accom-
plishment, explaining an additional 4% of the variance but, accomplishment. As can be seen in Table 5, the regression
for assistant nurses, demand and control, but not social coefficient for the environment variables that were statisti-
support, were related as expected, explaining an additional cally significant in the second step diminished and became
3% of the variance. It may be noted that the association insignificant when empowerment was added in the third
between social support and personal accomplishment was step. Only for assistant nurses was one statistically signifi-
stronger for registered nurses as compared to assistant cant moderator effect of empowerment on the association
nurses (b = 0.14/b = 0.04, respectively). For both groups, the between the environment variables and personal accom-
main effect of empowerment on personal accomplishment plishment observed. As can be seen from Figure 3, an
was positive and statistically significant as expected, increase in social support is related to higher degrees of
accounting for an additional 10%/7%, respectively, of the personal accomplishment in assistant nurses with low
variance. For both groups, empowerment had a mediating empowerment and to lower degrees of personal accom-
effect between the environment variables and personal plishment in assistant nurses with high empowerment.

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Journal Compilation © 2007 Blackwell Publishing Asia Pty Ltd.
210 J. Hochwälder

Table 5. Results from the hierarchical regression analyses, with personal accomplishment as the criterion variable

Personal accomplishment
Registered nurses Assistant nurses
b†step 1 bstep 2 bstep 3 bstep 4 bstep 1 bstep 2 bstep 3 bstep 4

Age -0.03 -0.03 -0.11*** -0.11** -0.02 -0.02 -0.06 -0.05


Gender‡ -0.00 -0.02 -0.01 -0.01 0.02 0.01 0.00 0.00
Demand – 0.01 0.06 0.07 – 0.01 0.04 0.04
Control – 0.13*** 0.00 0.00 – 0.17*** 0.05 0.04
Social support – 0.14*** 0.07 0.07* – 0.04 -0.04 -0.05
Empowerment – – 0.37*** 0.37*** – – 0.31*** 0.29***
Demand ¥ empowerment – – – -0.05 – – – 0.00
Control ¥ empowerment – – – -0.04 – – – -0.04
Social support ¥ empowerment – – – 0.02 – – – -0.11*
Model F 0.47 7.90*** 23.36*** 16.10*** 0.25 3.61 9.43 7.51
(d.f.) (2, 835) (5, 832) (6, 831) (9, 828) (2, 515) (5, 512) (6, 511) (9, 508)
R2 0.00 0.04 0.14 0.15 0.00 0.03 0.10 0.12
DR2 0.00 0.04*** 0.10*** 0.01 0.00 0.03*** 0.07*** 0.02*

*P < 0.05; **P < 0.01; ***P < 0.001. †b is the standardized regression coefficient; ‡women were coded with 0 and men with 1.

ating effect between the three work environment dimensions


and the three burnout dimensions. The mediating effect of
2 empowerment was especially apparent between the control
dimension and the three burnout dimensions. This result
implies that promoting aspects of control (and also social
Personal accomplishment

support) in the work environment should result in a higher


1
sense of empowerment which, in turn, should lead to lower
degrees of burnout.
The present study is similar to other studies exploring
0 moderating effects (Albertsen et al., 2001), in that few (three
significant effects out of the 18 possible effects) moderating
effects were observed. With regard to the first significant
–1 interaction, it is plausible that an increase in demands should
be related to a lower increase in emotional exhaustion in
subjects (registered nurses) with high empowerment as com-
pared to subjects with low empowerment. The second inter-
–2
action showed that for subjects (assistant nurses) with high
Low High empowerment, an increase in control resulted in less de-
Social support personalization, while for assistant nurses with low em-
powerment, an increase in control resulted in more
Figure 3. The interaction between social support and empower- depersonalization. Thus, having the opportunity to have
ment with regard to personal accomplishment for assistant nurses. control over one’s work (in terms of, for example, how and
---, low empowerment; ––, high empowerment. what should be done) without having any power (in terms of,
for example, competence and meaning) can lead to deper-
sonalization. This result is in line with Wallerstein’s (1992)
assertion that trying to change the individual’s sense of
DISCUSSION
control without changing the environmental conditions
In the present study, and in line with both theoretical reason- might result in even more ill health. This assertion has been
ing (Wallerstein, 1992) and empirical results (Hochwälder & confirmed by Schaubroeck and Merritt (1997), who found
Bergsten-Brucefors, 2005), empowerment had a significant that control can have negative health consequences among
main effect on burnout. After controlling for demographic individuals with low self-efficacy. The third interaction
and work environment variables, empowerment accounted showed that an increase in social support was related to
for an additional 3–10% of the variation in the three burnout higher degrees of personal accomplishment in subjects (assis-
dimensions. This result legitimates the use of empowerment tant nurses) with low empowerment and to lower degrees of
as a complement to the job demand-control-support model. personal accomplishment in subjects with high empower-
As suggested by Spreitzer (1997) and observed by Lasch- ment. Thus, an increase in social support might facilitate per-
inger et al. (2003), we found empowerment to have a medi- sonal accomplishment for those with low empowerment but

© 2007 The Author


Journal Compilation © 2007 Blackwell Publishing Asia Pty Ltd.
Empowerment 211

might hinder personal accomplishment for those with high Hochwälder J, Bergsten-Brucefors A. Psychological empowerment
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