Journal of Nursing Management, 2015

The influence of empowerment, authentic leadership, and professional practice environments on nurses’ perceived interprofessional collaboration SANDRA REGAN

RN, PhD

1

, HEATHER K. S. LASCHINGER

RN, PhD, FAAN

2

and CAROL A. WONG

RN, PhD

3

1

Assistant Professor, 2Distinguished University Professor, and 3Associate Professor, Arthur Labatt Family School of Nursing, Western University, London, Ontario, Canada

Correspondence Sandra Regan Western University Arthur Labatt Family School of Nursing 1151 Richmond Street London ON N6A 5C1 Canada E-mail: [email protected]

REGAN S., LASCHINGER H.K.S. & WONG C.A.

(2015) Journal of Nursing Management The influence of empowerment, authentic leadership, and professional practice environments on nurses’ perceived interprofessional collaboration Aim The aim of this study was to examine the influence of structural empowerment, authentic leadership and professional nursing practice environments on experienced nurses’ perceptions of interprofessional collaboration. Background Enhanced interprofessional collaboration (IPC) is seen as one means of transforming the health-care system and addressing concerns about shortages of health-care workers. Organizational supports and resources are suggested as key to promoting IPC. Methods A predictive non-experimental design was used to test the effects of structural empowerment, authentic leadership and professional nursing practice environments on perceived interprofessional collaboration. A random sample of experienced registered nurses (n = 220) in Ontario, Canada completed a mailed questionnaire. Hierarchical multiple regression analysis was used. Results Higher perceived structural empowerment, authentic leadership, and professional practice environments explained 45% of the variance in perceived IPC (Adj. R² = 0.452, F = 59.40, P < 0.001). Conclusions Results suggest that structural empowerment, authentic leadership and a professional nursing practice environment may enhance IPC. Implications for nursing management Nurse leaders who ensure access to resources such as knowledge of IPC, embody authenticity and build trust among nurses, and support the presence of a professional nursing practice environment can contribute to enhanced IPC.

Keywords: authentic leadership, empowerment, interprofessional collaboration, professional nursing practice environment Accepted for publication: 18 December 2014

Background Governments, health-care decision-makers and health professional associations have identified interprofessional collaboration (IPC) as an important policy approach for addressing patient safety issues, health human resource shortages, and transforming the health-care system (National Research Council 2000, DOI: 10.1111/jonm.12288 ª 2015 John Wiley & Sons Ltd

World Health Organisation 2010, Canadian Nurses Association 2011). Interprofessional collaborative practice ‘involves a partnership between a team of health professionals and a client in a participatory, collaborative, and coordinated approach to shared decision-making around health and social issues’ (Orchard et al. 2005). Research and policy syntheses have identified the role of IPC in positive patient 1

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outcomes and health care provider retention and job satisfaction (Barrett et al. 2007, Suter et al. 2012). Creating a workplace culture supportive of IPC is suggested as an important strategy to move the IPC policy agenda forward (Orchard et al. 2005). A number of attributes of IPC have been identified and include shared responsibility for client care, knowledge about IPC, trust and mutual respect among and between health-care professionals, and good communication (Martin-Rodriguez et al. 2005, Vyt 2008). When these attributes are present in the workplace, collaborative relationships are more likely to flourish. Organizational supports and resources, such as communicating a common vision and enhancing knowledge about IPC, are seen as having a positive influence on IPC (Clark & Greenwald 2013). The organizational context, particularly supportive leadership, is considered to be critical to enhancing IPC in health care (Nicholas et al. 2010). Indeed, organizational contexts can be an impediment to collaboration among nurses and physicians (Hughes & Fitzpatrick 2010, Clark & Greenwald 2013). The values and beliefs individuals and their collective profession hold about IPC can have an effect on the ability for different professions to work together collaboratively (Hall 2005). Historically, the nurse–physician relationship has been a source of conflict and hence impediment to realizing the ideal of IPC (Zwarenstein & Reeves 2002). Perceptions of teamwork, good communication and positive nurse–physician relationships have been identified as important aspects of collaboration (Crawford et al. 2012). Nurses are in a strategic position to promote a culture of IPC in health care because they are often the ones in leadership roles; however, some have suggested that nurses and the nursing profession have been more of a hindrance (Orchard 2010). The purpose of this study is to examine the effects of workplace environments and nursing leadership on experienced nurses’ perceptions of IPC.

Theoretical framework and relevant research The theoretical framework guiding this study is based on structural empowerment, authentic leadership, and professional nursing practice environments. An overview of each is provided here along with relevant research.

Structural empowerment According to Kanter’s theory (Kanter 1977, Laschinger 1996), structural empowerment relates to workplace 2

structures that enable employees to carry out their work in meaningful ways. These structures support employees by providing access to opportunity to grow and move within their organization, information to acquire the knowledge to effectively carry out their work, support in the form of peer and supervisor feedback and resources such as time and supplies to carry out their work (Kanter 1977). There is a considerable body of research supporting Kanter’s empowerment theory in nursing. A number of studies have found a relationship between empowerment and positive organizational and nurse outcomes including: higher job satisfaction (Laschinger 2008), decreased burnout (Greco et al. 2006), and increased civility and organizational trust (Laschinger et al. 2012). Research has shown that among new graduate nurses empowering practice environments and authentic nursing leadership have an important role in positive perceptions of IPC (Laschinger & Smith 2013). In a study of nurse practitioners working in acute and primary care, a strong association between workplace empowerment and perceived physician and manager collaboration was found (Almost & Laschinger 2002).

Authentic leadership Authentic leadership theory suggests that when leaders are authentic or true to their values and strengths, they enable others to do the same leading to a positive organizational culture and employee performance (Walumbwa et al. 2008). Authentic leadership is defined as ‘a pattern of transparent and ethical leader behaviour that encourages openness in sharing information needed to make decisions while accepting input from those who follow’ (Avolio et al. 2009). The authentic leader builds trust and healthier work environments through four components: self-awareness, balanced processing, internalised moral perspective and relational transparency (Walumbwa et al. 2008). Leaders who are authentic operate using ‘balanced processing’ by gathering sufficient opinions and viewpoints from others before making important decisions. They reinforce a level of openness with others (relational transparency) that provides them an opportunity to be forthcoming with their ideas, challenges and opinions. The authentic leader sets and rolemodels a high standard of ethical and moral conduct (internalised moral perspective) and, finally, demonstrates self-awareness by understanding not only their own strengths, weaknesses and limitations, but how they affect others. Authentic leaders who embody ª 2015 John Wiley & Sons Ltd Journal of Nursing Management

Perceived interprofessional collaboration

these behaviours are thought to build cultures of trust and respect and contribute to healthier work environments (Wong & Cummings 2009). Studies have found that authentic leadership is linked to nurses’ trust in managers (Wong et al. 2010), which is an important attribute of IPC. In addition, Giallonardo et al. (2010)investigated the role of preceptors’ authentic leadership on work attitudes of new graduate nurses and found that authentic leadership was significantly related to work engagement and job satisfaction. Authentic leadership has been shown to be a significant independent predictor of perceived quality of IPC in new graduate nurses (Laschinger & Smith 2013). In their systematic review update of studies on nursing leadership and patient outcomes, Wong et al. (2013) indicated that positive leadership styles such as authentic leadership may be associated with enhanced teamwork. They also suggested that leaders influence outcomes through how they shape the work environment or influence staff perceptions, including expectations of collaborative relationships.

Professional practice environments Professional nursing practice environments have garnered a great deal of attention in the context of nurse shortages in the 1980s and questions about the impact of nurse staffing on patient outcomes. According to the American Association of Colleges of Nursing, professional nursing practice environments reflect eight ‘hallmarks’ supportive of professional nursing practice: 1 Manifest a philosophy of clinical care emphasizing quality, safety, interdisciplinary collaboration, continuity of care, and professional accountability; 2 Recognise contributions of nurses’ knowledge and expertise to clinical care quality and patient outcomes; 3 Promote executive-level nursing leadership; 4 Empower nurses’ participation in clinical decisionmaking and organization of clinical care systems; 5 Maintain clinical advancement programmes based on education, certification, and advanced preparation; 6 Show professional development support for nurses; 7 Create collaborative relationships among members of the health-care provider team; and 8 Use technological advances in clinical care and information systems (American Association of Colleges of Nursing 2002). Magnet hospitals, so-called because of their ability attract and retain nurses and being supportive of professional nursing practice, were studied extensively ª 2015 John Wiley & Sons Ltd Journal of Nursing Management

and thought to reflect characteristics that made for a ‘good place to work’, including strong and visible nursing leadership and nurse autonomy and responsibility for patient care (Kramer & Hafner 1989, Lake 2002). Health-care organisations that enable professional nursing practice environments are associated with positive nurse outcomes such as higher job satisfaction, higher perceptions of trust, lower burnout, and lower intention to leave, and patient outcomes such as higher perceived quality of care and lower mortality and morbidity (Aiken et al. 2008, Djukic et al. 2013). Characteristics of professional nursing practice environments include greater nurse control over practice and decisions about patient care, positive perceptions of team work, and good relationships with physicians (Lake 2002, 2007); all of which are important aspects of a culture supportive of IPC (Orchard et al. 2005). Laschinger et al. (2003) found that empowering work environments in the presence of magnet hospital characteristics such as control over practice, autonomy and good nurse–physician relationships were predictive of nurse job satisfaction. The authors suggest that empowered work environments are the antecedent to nurse perceptions of a supportive professional practice environment. No studies were found that explicitly measured professional nursing practice environments and nurses’ perceptions of IPC.

Hypothesis We hypothesised that experienced nurses who perceived higher levels of structural empowerment, authentic leadership, and a professional nursing practice environment would have higher perceived interprofessional collaboration.

Methods Design A predictive non-experimental design was used. Our hypothesised model was tested using data from the first wave and a subsample of a larger longitudinal study of experienced nurses in Ontario, Canada. Approval for the larger study was obtained from the University of Western Ontario ethics review board.

Sample A random sample of experienced registered nurses (those with greater than 5 years’ experience) was drawn from the College of Nurses of Ontario 3

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regulatory database of practising nurses. Questionnaires were mailed to 2012 registered nurses with 265 questionnaires returned (13% response rate). Owing to incomplete responses, the final sample for the analysis reported here was 220 experienced registered nurses in staff nurse positions. To ensure that the analysis was adequately powered, based on beta of 0.80, alpha of 0.05, medium effects size and three predictors, a minimum sample size of 84 was required.

Instruments Data were collected with a mailed questionnaire including standardised instruments for the study variables. Four instruments were used to measure the key study variables in this analysis. Structural empowerment was measured using the Conditions of Work Effectiveness Questionnaire – II (CWQ-II) (Laschinger et al. 2001). The CWQ-II consists of 12 items on four subscales measuring key dimensions of empowerment (access to opportunity, information, support, and resources) on a Likert scale of 1–5 (1 = none; 5 = a lot). Structural empowerment is the sum of all 12 items. Numerous studies have demonstrated acceptable instrument reliability and validity (Laschinger 2013). The Authentic Leadership Questionnaire (ALQ) was used to measure nurses’ perceptions of their current leader’s behaviours (Avolio et al. 2012). The ALQ comprises 16 items divided among four scales (selfawareness, transparency, internalised moral perspective, and balanced processing) measured on a Likert scale of 0–4 (0 = not at all; 4 = frequently, if not always). Scales are summed and averaged to provide an ALQ score. Previous studies using the ALQ have demonstrated acceptable reliability and confirmatory factor analysis has supported the four dimensions of the ALQ (Walumbwa et al. 2008). A subset of six items from Nursing Work IndexRevised (NWI-R) were selected to measure attributes of the professional nursing practice environment (Aiken & Patrician 2000). The NWI-R has been utilised in nursing and hospital outcomes studies (Choi et al. 2004, Aiken et al. 2008) and studies have reported acceptable reliability and validity (Estabrooks et al. 2002). The items selected for this study measured perceptions of control over own practice, autonomous decision-making regarding patient care, nurse–physician relationships and teamwork, sufficiency of nurses to provide quality patient care, and continuity of care on a Likert scale of 1–4 4

(1 = strongly disagree; 4 = strongly agree). The six items were summed and averaged for a professional nursing practice environment score. An exploratory factor analysis (EFA) of the NWI items using principal components extraction and varimax rotation showed a one-factor solution explaining 52% of the variance, with all items loading above 0.50. The Interprofessional Collaboration Scale (IPCS) was used to measure perceived IPC. The IPCS is a researcher-developed scale based on an extensive review of the literature (Laschinger & Smith 2013). It measures perceptions that health professionals collaborate effectively to provide patient care, that IPC is highly valued on their unit, that their knowledge is respected by other health professionals when they participate in interprofessional groups, and that healthcare professionals on their unit understand each other’s role in providing holistic patient care. A previous study showed acceptable reliability (Cronbach’s a = 0.75) (Laschinger & Smith 2013). The IPCS consists of four items on a Likert scale of 1–5 (1 = strongly disagree; 5 = strongly agree). The four items are summed and averaged to provide an IPC score. An EFA conducted using principal components extraction and varimax rotation showed a one-factor solution explaining 77.5% of variance with all items loading above 0.80.

Data analysis Descriptive statistics and multiple regression analyses were conducted using the Statistical Package for Social Sciences (SPSS) version 21 (IBM Corporation 2013).

Results Participant characteristics Registered nurses working in staff nurse positions (n = 220) were mostly female (96%), with an average of 47.8 years of age and with an average of 22.1 years of experience. Most nurses worked full time (71%) with the remaining working part-time (22%) or casually (7%) and had been with their organisation an average of 13.6 years. The majority of nurses worked in hospital (65%) with the remaining nurses in longterm care (17%), community (11%) and other (7%). There were no statistically significant differences for any of the key study variables based on place of work. The sample characteristics are similar to the general population of nurses in Ontario (College of Nurses of Ontario 2013). Nearly 80% of nurses indicated that ª 2015 John Wiley & Sons Ltd Journal of Nursing Management

Perceived interprofessional collaboration

their immediate supervisor was a nurse and 61% of nurses interacted with their manager at least once a week.

Discussion The results supported our hypothesis that higher levels of structural empowerment, authentic leadership, and the presence of a professional nursing practice environment are predictive of higher perceived IPC (adjusted R2 = 0.452). Structural empowerment, authentic leadership and professional nursing practice environment were all significant independent predictors of IPC although they differ in their effect. The importance of organizational context is demonstrated by the similar magnitudes of structural empowerment and the professional nursing practice environment (b = 0.287 and b = 0.326, respectively). Empowering workplaces and professional nursing practice environments, the organisational contexts, are foundational to

Descriptive results Means and standard deviations along with reliability statistics and correlations for study variables are found in Table 1. Nurses reported relatively high perceptions of interprofessional collaboration (mean = 3.79), and moderate perceptions of structural empowerment (mean = 12.50), presence of authentic leadership (mean = 2.28) and presence of professional nursing practice environment (mean = 2.84). All scales demonstrated acceptable reliability (Cronbach’s a >0.80). All study variables were positively correlated (P < 0.01).

Table 2 Hierarchical regression results for all models

Multiple regression analysis Hierarchical multiple regression results supported the hypothesised model. The variable ‘structural empowerment’ was entered in the first block and explained 33% of the variance in interprofessional collaboration. The variable ‘authentic leadership’ was added to the model and explained an additional 4% of the variation. In the final model, the ‘professional nursing practice environment’ variable was entered explaining an additional 7% of the variance in IPC. In the final model, all three variables were significant independent predictors of interprofessional collaboration explaining 45% of the variation (Adjusted R² = 0.452, F = 59.40, P < 0.001) (see Table 2 for details of the models and Figure 1 for the final model).

Models

B (SE)

b

DR2



t-statistic*

Structural empowerment

0.170 (0.016)

0.576

0.332

0.332

10.41

Structural empowerment Authentic leadership

0.124 (0.020)

0.421

0.219 (0.055)

0.264

0.085 (0.020)

0.287

4.29

0.166 (0.053)

0.200

3.15

0.468 (0.086)

0.326

Structural empowerment Authentic leadership Professional nursing practice environment

6.35 0.045

0.074

0.378

0.452

3.98

5.41

Outcome: interprofessional collaboration. B, unstandardised beta; SE, standardised error; b, standardised beta; DR2, delta R-squared. *All values statistically significant at P < 0.01.

Table 1 Means, standard deviations, reliability and correlations among study variables

1 2 3 4 5 6 7 8 9 10 11 12

Variable

Range

Mean (SD)

a†

1

2

3

4

5

6

7

8

9

10

11

Structural Empowerment Opportunity Information Support Resources Authentic Leadership Relational transparency Internalised moral perspective Balanced processing Self-awareness Professional Nursing Practice Environment Interprofessional Collaboration

4–20 1–5 1–5 1–5 1–5 0–4 0–4 0–4 0–4 0–4 1–4

12.50 3.83 2.99 2.90 2.83 2.28 2.40 2.40 2.23 2.09 2.84

(2.89) (0.86) (1.01) (0.98) (0.90) (1.04) (1.03) (1.10) (1.12) (1.16) (0.60)

0.85 0.86 0.88 0.84 0.81 0.97 0.90 0.93 0.89 0.95 0.82

– 0.76 0.79 0.80 0.66 0.59 0.55 0.59 0.51 0.55 0.51

– 0.51 0.47 0.34 0.43 0.35 0.42 0.40 0.43 0.36

– 0.51 0.32 0.35 0.32 0.35 0.29 0.32 0.28

– 0.45 0.61 0.59 0.58 0.53 0.57 0.45

– 0.43 0.41 0.45 0.35 0.39 0.51

– 0.92 0.94 0.95 0.95 0.43

– 0.85 0.79 0.81 0.37

– 0.84 0.83 0.42

– 0.90 0.42

– 0.42



3.79 (0.85)

0.90

0.57

0.48

0.36

0.50

0.42

0.51

0.47

0.50

0.47

0.48

0.56

1–5

12



Note: All correlations statistically significant at P < 0.01. †Cronbach’s alpha. ª 2015 John Wiley & Sons Ltd Journal of Nursing Management

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Figure 1 Hierarchical regression results for final model.

IPC (Nicholas et al. 2010). In addition, experienced nurses’ perceptions of IPC are affected by authentic leadership behaviours (b = 0.200), suggesting that nursing leaders have an important role in supporting IPC. Our findings are consistent with Laschinger and Smith (2013) who found that new graduate nurses’ perceptions of IPC were related to empowering work environments and the presence of authentic leaders. This suggests that for both new graduate nurses and experienced nurses, organizational contexts and positive leadership are important supports to improved IPC. Strategies to enhance workplace structures aimed at both new graduates and experienced nurses may have an important role in perceptions of IPC for all nurses. The addition of the variable measuring professional nursing practice environments in our model explains more variance in experienced nurses’ perceptions of IPC (adjusted R2 = 0.45) than empowering work environments and authentic leadership only (adjusted R2 = 0.38). Of interest is the stronger influence of the professional nursing practice environment variable (b = 0.326) on perceptions of IPC vs. empowering work environments (b = 0.287) and authentic leadership (b = 0.200). This suggests that not only do empowering work environments and authentic leadership behaviours influence positive perceptions of IPC in experienced nurses but characteristics such as control over their own practice, autonomous decisionmaking regarding patient care and continuity of care may shape experienced nurses’ ability to collaborate interprofessionally. This finding provides additional strategies for nurse leaders to consider to enhance IPC in the health-care setting. Structural supports in the workplace such as access to support in the form of feedback from peers and time to develop relationships with team members can be strategic for developing competencies to participating in IPC. Access to information such as knowledge about IPC, how to work in teams, and the roles and 6

responsibilities of other health-care professionals have been identified as important competencies of IPC (Bainbridge et al. 2010). Nurses may perceive higher IPC when their nurse leaders exhibit behaviours consistent with authentic leadership. Laschinger and Smith (2013) note that new graduate nurses’ perceptions of IPC were related to their feelings that relationships among the health professional team were valued and that their knowledge was respected. Wong et al. (2013) suggest that authentic nurse leaders can create a culture that encourages these values and role model characteristics such as respect for others and how to work collaboratively within a team context. Nurses may feel more confident (and perhaps less threatened) participating in interprofessional collaborative practice when they practice in an environment that supports and recognises their professional role. When nurses have control over their own practice and have the autonomy to make patient care decisions they have higher levels of job satisfaction (Laschinger et al. 2003). Low levels of professional autonomy are associated with lower levels of nurse–physician collaboration (Papathanassoglou et al. 2012) which could impede the quality of IPC. Environments where nurses work collaboratively with physicians and feel part of a team are foundational to trusting team members (Clark & Greenwald 2013). Adequate nurse staffing along with continuity of care are also important elements of professional practice environments and may provide opportunities to build relationships between and among healthcare professionals and clients which are key aspects of interprofessional collaborative practice (Orchard et al. 2005).

Limitations The data were drawn from one point in time, which limits the capacity to draw causal inferences. This ª 2015 John Wiley & Sons Ltd Journal of Nursing Management

Perceived interprofessional collaboration

limitation is addressed in part by the use of our theoretical framework and statistical modelling. As with most mailed surveys, low response rates are a limitation. However, the sample characteristics in our study are similar to the nurse population characteristics, suggesting that the sample may be representative.

Conclusion In order to achieve the ideal of IPC, organizations must create a culture that supports nurses and others to practice collaboratively. Nurse leaders can enhance nurses’ capacity for IPC through empowering work environments, supporting professional nursing practice, and role-modelling behaviours consistent with IPC. Rather than hindering IPC, nurse leaders can transform the work environment to enhance collaborative practice.

Implications for nursing management Nurse leaders can ensure that nurses have access to information about how to work in teams and the roles and responsibilities of those with whom nurses work can assist them towards better practice in a collaborative manner. Professional nursing practice environments that support nurses to have control over their practice and exercise professional autonomy may enhance nurse confidence working in interprofessional teams. Nurse leaders can promote the importance of IPC by attending to the four dimensions of authentic leadership such as self-awareness of their own participation in IPC. Role modelling behaviours that are consistent with collaborative practice, such as trust and mutual respect among and between health-care professionals, shared decision making and attention to the professional ethical standards behind decision processes and outcomes, are ways that nurse leaders can enhance support for IPC.

Acknowledgements The author’s would like extend their gratitude to the Ontario registered nurses who participated in this study.

Source of Funding This study was funded by the Ontario Ministry of Health and Long-Term Care (Grant #06652)

ª 2015 John Wiley & Sons Ltd Journal of Nursing Management

Ethical approval The Research Ethics Board at the University of Western Ontario granted approval to conduct the study.

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ª 2015 John Wiley & Sons Ltd Journal of Nursing Management

The influence of empowerment, authentic leadership, and professional practice environments on nurses' perceived interprofessional collaboration.

The aim of this study was to examine the influence of structural empowerment, authentic leadership and professional nursing practice environments on e...
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