JONA Volume 46, Number 2, pp 95-100 Copyright B 2016 Wolters Kluwer Health, Inc. All rights reserved.
THE JOURNAL OF NURSING ADMINISTRATION
The Relationship of Clinical Nurses_ Perceptions of Structural and Psychological Empowerment and Engagement on Their Unit Jean Marie DiNapoli, MS, RN Deirdre O_Flaherty, MSN, APRN, BC, NE, ONC Carol Musil, PhD, RN, FAAN, FGSA
Joanne T. Clavelle, DNP, RN, NEA-BC, FACHE Joyce J. Fitzpatrick, PhD, RN, FAAN
OBJECTIVE: The purpose of this study was to describe relationships between structural empowerment, psychological empowerment, and engagement among clinical nurses. BACKGROUND: Empowerment and engagement are key drivers of retention and quality in healthcare. Creating an empowering culture and an engaged staff supports initiatives that are essential for positive work environments. METHODS: A survey of 280 nurses in a national conference was conducted using the Conditions of Work Effectiveness, Psychological Empowerment Instrument, and the Utrecht Work Engagement Scale. Pearson correlation coefficients and multiple regression analysis were used to determine relationships between demographic data and study variables. RESULTS: Overall, nurses had high perceptions of structural empowerment and psychological empowerment and were moderately engaged. Also, significant positive relationships were found between the key study variables.
CONCLUSIONS: Results show positive correlations between empowerment and perceived engagement among clinical nurses.
Author Affiliations: Associate Director of Nursing (Ms DiNapoli), The Institute for Advanced Medicine, Mount Sinai Health System; and Senior Administrative Director (Ms O_Flaherty), Patient Care Services Surgical Nursing, Lenox Hill Hospital, New York, New York; Elizabeth Brooks Ford Professor of Nursing (Dr Fitzpatrick) and The Marvin E. and Ruth Durr Denekas Professor of Nursing (Dr Musil), Francis Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio; Senior Vice President and Chief Clinical Officer (Dr Clavelle), HonorHealth, Scottsdale, Arizona. The authors declare no conflicts of interest. Correspondence: Ms DiNapoli, Mount Sinai Health System, 17 E 102nd St, Box 1009 New York, NY 10029 (Jean.dinapoli@ mountsinai.org). DOI: 10.1097/NNA.0000000000000302
The complexity of the healthcare system today challenges hospitals to provide safe, patient-centered, and cost-effective care. Economic constraints, changes in payment structures, the shift to value-based care, and increased emphasis on prevention are important forces in care delivery. Studies have shown that nurses who perceive their work environments as empowering have increased job satisfaction1 and increased patient satisfaction,2 provide higher quality of care,3,4 have better patient outcomes,5 and are more engaged.3,4,6-8 Kanter_s9 theory of structural empowerment (SE) has been widely applied in nursing research and practice. Kanter defined SE as the ability to get things done in an organization by having access to information, resources, opportunity, and support. Kanter acknowledged that management plays a significant role in the provision of these structural factors and posited that empowered leaders are more effective in empowering their employees, resulting in an increased commitment to ensuring the organizational goals are achieved.9 In addition to structural components, psychological empowerment is the emotional investment needed for staff to be successful.10 The process of psychological empowerment is influenced by the employee_s work environment and is demonstrated in 4 core concepts: meaning, competence, self-determination, and impact. Spreitzer10 further discussed that positive relationships can be seen between the core concepts of structural
JONA Vol. 46, No. 2 February 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
95
and psychological empowerment and its influence on empowering behaviors. The encouragement of an empowering environment fosters an individual_s perception of competence and selfefficacy, which provides them with the confidence to believe that they are able to meet the demands of the job. Spreitzer10 suggests that an environment that has a solid foundation of the structural and psychological core concepts alone does not necessarily promote an empowered staff. It is important that the individual is engaged and understands that their work has impact and is meaningful. Wang and Liu_s8 study explored the relationships among professional nursing practice, psychological empowerment, and nurse work engagement. The results of their study showed a significant relationship among these factors and provided a more complete understanding of how professional practice influences nurse engagement. Work engagement has been defined as a positive, fulfilling, work-related state of mind that is characterized by vigor, dedication, and absorption.11 Staff who are engaged enjoy going to work, feel valued, and relish the work that they do. Jenaro et al12 determined from their research that improvements in social and communication skills are needed for nurses to experience vigor and dedication, attributes of work engagement. Bakker et al13 hypothesized that employees are more likely to be engaged when their organizations provide a supportive, inclusive, and challenging environment that supports employees_ psychological needs. The management literature provides evidence for the relationship of workplace empowerment and employee engagement, but there has been minimal nursing research linking these variables. Laschinger et al4 were the 1st to examine the impact of empowering work environments on nurses_ work engagement and effectiveness. They highlighted the role of empowerment in promoting work engagement and effectiveness. Havens et al14 found nurses were more engaged when they felt their work environments promoted professional nursing practice. Other studies have shown positive work environments and staff engagement and empowerment are related to lower nurse turnover, increased autonomy, shared governance,15 and interdisciplinary teamwork.11,16,17 However, few studies have examined the relationships between perceptions of empowerment and engagement on the unit. Therefore, the purpose of this study was to describe relationships between SE, psychological empowerment, and engagement on the unit, among clinical nurses.
Methods Design and Research Questions The study used a national sample and a descriptive correlational design. The research questions were as follows:
96
What are the relationships between clinical
nurses_ SE, psychological empowerment, and engagement? How do clinical nurses_ background characteristics, SE, and psychological empowerment affect engagement? Sample A sample of RNs was obtained from the National Association of Orthopedic Nursing annual conference attendees in May 2014. Three hundred fifty participants completed the survey, with a final sample of 280; those who did not meet the following inclusion criteria were excluded. Inclusion criteria for this study were RNs with at least 1 year of experience on their unit and practicing full time in an acute care setting. RNs who worked part time or were in a leadership role, advanced practice nurses, or nurses who have worked on their unit for less than 1 year were excluded. Institutional review board approval was granted by Case Western Reserve University. Instruments Structural empowerment was measured with the Conditions of Work Effectiveness Questionnaire II (CWEQ-II),18 which consists of 19 items that measure the 6 components of SE described by Kanter (opportunity, information, support, resources, formal power, and informal power). A total empowerment score is obtained by summing the 6 subscale total scores, ranging from 6 to 30. Higher scores represent stronger perceptions of working in an empowered environment. Cronbach_s ! coefficients for the CWEQ-II subscales have been reported to range from .78 to .93.17 In the present study, Cronbach_s !_s ranged from .81 to .91 for the subscales, .92 for the total score. Psychological empowerment was measured using the Psychological Empowerment Instrument (PEI),10 a 12-item questionnaire with 4 dimensions: meaning, competence, self-determination, and impact. Each component is measured on a 7-point Likert scale, and total empowerment scores are obtained by averaging the total subscale scores. Higher scores represent higher levels of perceived psychological empowerment experienced at work. DeCicco et al19 reported ! coefficients ranging from .85 to .93, .85 for total score. In the present study, Cronbach_s !_s ranged from .85 to .91 for subscales, .91 for total score. Engagement was measured using the Utrecht Work Engagement Scale (UWES-9),20 a 9-item instrument that measures 3 components of work engagement: vigor (3 items), dedication (3 items), and absorption (3 items). These items are rated on a 7-point Likert scale ranging from never to always. Each subscale is averaged to
JONA Vol. 46, No. 2 February 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
produce a total scale score between 0 and 6, with higher scores representative of greater work engagement. The same process is used to obtain the total score. Schaufeli et al20 reported the Cronbach_s !_s varying from .89 to .97 (median, .93). In the present study, Cronbach_s !_s ranged from .75 to .84 for subscale scores, .91 for total score. A background questionnaire was used to collect data on age, gender, race, and ethnicity. Participants were also asked how many years they have worked as a nurse, which shift they work (12-hour day/night vs 8-hour day/evening/night or another shift), the highest degree achieved (diploma, associate degree, baccalaureate degree, master_s degree, or doctorate degree), if they hold a certification in nursing, and if they work at a Magnet -designated institution. A
Data Analysis Frequency distributions were used to describe the percentage of responses to the demographic variables of age, gender, race, ethnicity, years as a nurse, shift worked, certification status, highest degree achieved, and hospital_s Magnet status. Measures of central tendency, range, and SD were obtained to describe each demographic variable. Correlational analyses were used to answer the 1st research question. Multiple regression analysis was used to determine relationships between the demographic factors of age, ethnicity (Hispanic vs non-Hispanic), years as a nurse, shift worked (12- vs 8-hour shift), and structural and psychological empowerment with engagement.
Results The majority of participants were female (93.6%) and white (75.4%), with an average age of 44 years. They held a bachelor_s degree (60.0%) and had a certification in nursing (71.8%) (Table 1). Overall, nurses perceived their work environments as highly structurally empowering (mean, 23.33 [SD, 3.60]). Nurses perceived they had access to opportunity (mean, 4.23 [SD, 0.67]) and informal power (mean, 4.14 [SD, 0.72]). Access to resources was the lowest of the 6 subscales. The scores on psychological empowerment indicated that nurses were highly empowered with a mean of 5.61 (SD, 0.8). Nurses felt their work had meaning to the organization (mean, 6.04 [SD, 1.0]) but only moderate impact on the organizations outcomes (mean, 5.02 [SD, 1.20]). The clinical nurses in this study perceived themselves to be moderately engaged (mean, 4.76 [SD, 0.81]), with absorption having the highest subscore (mean, 5.03 [SD, 0.77]). The means and SDs of the major
Table 1. Demographic Data n Age
Minimum Maximum Mean
279
Gender
Male Female Transgender Race Alaskan or Native American Asian Black/African American Mixed race Native Hawaiian/ Pacific Islander White Other Total Ethnicity Hispanic or Latino Non-Hispanic or non-Latino Other Total Shift Day 12 h Night 12 h Day 8 h Evening/night 8 h Other Total Certified Yes No Years as RN
n 276
Degree
23
75
n
%
17 262 1 3
6.1 93.6 0.3 1.1
40 13
14.3 4.6
5 3
1.8 1.1
211 3 278 8 190
75.4 1.1
42 240 126 39 81 10 24 280 201 79
15.0
44
2.9 67.9
45 13.9 28.9 3.6 8.6 71.8 28.2
Minimum Maximum Mean 1
54
n
%
Diploma 11 Associate degree 61 Baccalaureate degree 168 Master_s degree 40 Magnet Yes 125 No 150
17.3
3.9 21.8 60.0 14.3 44.6 53.6
study variables and subscales of each instrument are presented in Table 2. Correlations Between Structural Empowerment, Psychological Empowerment, and Engagement To determine the relationships between the clinical nurses_ SE, psychological empowerment, and engagement, the Pearson correlation coefficients were examined. There was a moderate, positive correlation between total scores of SE and psychological empowerment (r = 0.40, P < .001). Additional analysis of the data revealed low to moderate, positive correlations between the majority of the subscales. Analysis of the relationships between SE, psychological empowerment, and engagement revealed moderate and positive correlations. There was a positive relationship between the overall SE score and
JONA Vol. 46, No. 2 February 2016
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Table 2. Descriptive Statistics of Major Study Variables
CWEQ-II Opportunity Information Support Resources Formal power Informal power Total empowerment PEI Competence Meaning Impact Self-determination Total psychological empowerment UWES Vigor Dedication Absorption Total engagement
Mean
SD
Cronbach_s !
4.23 3.96 3.98 3.32 3.67 4.14 23.33
0.67 0.87 0.84 0.87 0.88 0.72 3.60
.81 .90 .91 .85 .85 .81 .92
5.92 6.04 5.02 5.45 5.61
0.99 1.00 1.20 1.18 0.87
.85 .91 .89 .88 .91
4.58 4.68 5.03 4.76
0.95 0.99 0.77 0.81
.84 .81 .75 .91
engagement (r = 0.43, P < .001). There was a positive moderate correlation between total scores of psychological empowerment and engagement (r = 0.31, P < .001). For research question 2, a hierarchical multiple regression analysis was conducted to evaluate the influence of structural and psychological empowerment and the background variables of ethnicity, shift, years as an RN, and age on engagement. Structural empowerment and age were the only variables shown to significantly predict engagement; older age and greater SE predicted more engagement and accounted for 27% (adjusted R2) of the variance in engagement.
Discussion This study is the first to evaluate the relationships between nursing SE, psychological empowerment, and engagement. The results reflected nurses feeling highly empowered and engaged and showed positive correlations between SE, psychological empowerment and engagement. Access to resources was scored the lowest in the domain of SE, which is consistent with results from previous empowerment studies1,21 and not surprisingly considering our current healthcare environment where resources are often limited because of factors ranging from financial restrictions to staff availability. The psychological empowerment dimensions, meaning, and competence yielded the most significant subscales scores. Yet the correlations between these scores with the dimensions of SE were low and often not significant. This could be indicative
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of the nurses feeling their work is meaningful and important, and they have the knowledge and skill set to render quality patient care regardless of their work environment. The positive relationship between psychological empowerment and engagement is consistent with previous studies.1,8 Conversely, the high level of competence reported and its lack of significant correlation with engagement could be indicative of the reported level of specialty certifications that these nurses have achieved, which leads us to believe that they are confident in their ability to provide care, regardless of their level of engagement. The positive relationship seen between the overall SE score with engagement is consistent with previous studies.4,7 Staff empowerment is necessary in creating positive work environments leading to job satisfaction and decreased turnover.3,6,22 These results are consistent with Wang and Liu_s8 and Leiter and Laschinger_s23 studies and further support the perception that empowering and supportive work environments have staff who are more likely to be engaged. In addition, results of this study revealed high empowerment scores, which have differed from results in previous studies. This may be indicative of our sample population of nurses who are attending a national conference, have baccalaureate degrees, and have specialty certifications. Analysis of background data showed the full-time nurses in our study perceived themselves to have more access to information, resources, opportunity, and support, therefore increasing their engagement on the unit. The information gleaned from the multiple regression analysis provides us with data that support the expectation that empowering work environments influence engagement of the nursing staff. Surprisingly, the results did not reflect a significant difference in engagement on the unit between nurses working 8-hour shifts versus those working 12-hour shifts. Although this has not been previously reported, it was thought that there would be a significant difference. Another surprising result not seen was the lack of a significant relationship between nurses working in a Magnet environment and engagement on the unit.
Limitations Limitations with this study could be associated with the design and sampling methodology utilized. Results might be affected by the convenience sample of participants attending a conference.
Future Implications for Nurse Leaders Results from this study have shown the logical expectation that empowering work environments foster
JONA Vol. 46, No. 2 February 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
staff engagement. Therefore, the value nurses attribute to their work environment and the relationships between empowerment and engagement is one that nurse leaders need to embrace. Nurse managers play a key role in developing an empowering work environment by facilitating the tools needed for support, guidance, and influencing positive change.24 They are responsible for maintaining high-quality care and job satisfaction, in an environment that often lacks human and financial resources.25 Competing priorities and additional responsibilities add a layer of complexity to the nurse manager_s role, with the push to do more with less; it can be a challenge to foster and create an empowering work environment. They must consider the relationship between SE, psychological empowerment, and engagement, when designing any change that may be necessary to meet the complexity of the healthcare system today. Our past practices may no longer be aligned with the switch to both value and evidence-based care. Successful organizations will be challenged to do more with less, and nurses being the largest discipline providing direct patient care are in a strategic position. Nurses who are empowered and engaged will be more likely to accept and thrive in this new environ-
ment than nurses who are not. Passionate, empowered, and engaged clinical nurses are often the informal leaders, have considerable influence, seek advanced degrees and/or certifications, and pursue a career path that builds upon their experience, thus affording professional growth.
Conclusion This study has demonstrated the impact empowering work environments have on engagement. Nurses who are not engaged see their profession, leaders, and colleagues differently, and it will take a creative leadership approach to engage them, if at all. Work engagement is a motivational factor, which can lead to job satisfaction and lower turnover. Leaders can then focus their efforts to sustaining empowering work environments, and staff engagement can be harnessed to develop programs and initiatives that support quality care and move the profession forward. A strong relationship exists between empowerment and engagement, both essential in driving a high-performing work unit. Nurse leaders who lead a unit where nurses feel a strong sense of pride and are engaged in their work will see the benefits of quality patient care.
References 1. Purdy N, Laschinger HK, Finegan J, Kerr M, Olivera F. Effects of work environments on nurse and patient outcomes. J Nurs Manag. 2010;18(8):901-913. 2. Donahue MO, Piazza IM, Griffin MQ, Dykes PC, Fitzpatrick JJ. The relationship between nurses_ perceptions of empowerment and patient satisfaction. Appl Nurs Res. 2008;21(1):2-7. 3. Greco P, Laschinger HK, Wong C. Leader empowering behaviors, staff nurse empowerment and work engagement/burnout. Nurs Leadersh (Toronto, ON). 2006;19(4):41-56. 4. Spence Laschinger HK, Wilk P, Cho J, Greco P. Empowerment, engagement and perceived effectiveness in nursing work environments: does experience matter? J Nurs Manag. 2009; 17(5):636-646. 5. Wong CA, Spence Laschinger HK, Cummings GG. Authentic leadership and nurses_ voice behavior and perceptions of care quality. J Nurs Manag. 2010;18(8):889-900. 6. Cicolini G, Comparcini D, Simonetti V. Workplace empowerment and nurses_ job satisfaction: a systematic literature review. J Nurs Manag. 2014;22(7):855-871. 7. Boamah S, Laschinger H. Engaging new nurses: the role of psychological capital and workplace empowerment. J Res Nurs. 2015;20(4):265-277. 8. Wang S, Liu Y. Impact of professional nursing practice environment and psychological empowerment on nurses_ work engagement: test of structural equation modelling. J Nurs Manag. 2015;23(3):287-296. 9. Kanter RM. Men and Women of the Corporation. 2nd ed. New York, NY: Basic Books; 1993. 10. Spreitzer GM. Psychological empowerment in the workplace: dimensions, measurement and validation. Acad Manage J. 1995;38(5):1442-1462.
11. Schaufeli WB, Bakker AA. Defining and measuring work engagement bringing clarity to the concept. In: Work Engagement: A Handbook of Essential Theory and Research. New York, NY: Psychology Press; 2011:10-24. 12. Jenaro C, Flores N, Orgaz MB, Cruz M. Vigour and dedication in nursing professional: towards a better understanding of work engagement. J Adv Nurs. 2011;67(4):865-875. 13. Bakker A, Albrecht S, Leiter M. Work engagement; further reflections on the state of play. Eur J Work Organ Psychol. 2011;20:74-88. 14. Sullivan Havens D, Warshawsky NE, Vasey J. RN work engagement in generational cohorts: the view from rural US hospitals. J Nurs Manag. 2013;21(7):927-940. 15. Clavelle JT, O_Grady TP, Drenkard K. Structural empowerment and the nursing practice environment in Magnet organizations. J Nurs Adm. 2013;43(11):566
THE JOURNAL OF NURSING ADMINISTRATION
The Relationship of Clinical Nurses_ Perceptions of Structural and Psychological Empowerment and Engagement on Their Unit Jean Marie DiNapoli, MS, RN Deirdre O_Flaherty, MSN, APRN, BC, NE, ONC Carol Musil, PhD, RN, FAAN, FGSA
Joanne T. Clavelle, DNP, RN, NEA-BC, FACHE Joyce J. Fitzpatrick, PhD, RN, FAAN
OBJECTIVE: The purpose of this study was to describe relationships between structural empowerment, psychological empowerment, and engagement among clinical nurses. BACKGROUND: Empowerment and engagement are key drivers of retention and quality in healthcare. Creating an empowering culture and an engaged staff supports initiatives that are essential for positive work environments. METHODS: A survey of 280 nurses in a national conference was conducted using the Conditions of Work Effectiveness, Psychological Empowerment Instrument, and the Utrecht Work Engagement Scale. Pearson correlation coefficients and multiple regression analysis were used to determine relationships between demographic data and study variables. RESULTS: Overall, nurses had high perceptions of structural empowerment and psychological empowerment and were moderately engaged. Also, significant positive relationships were found between the key study variables.
CONCLUSIONS: Results show positive correlations between empowerment and perceived engagement among clinical nurses.
Author Affiliations: Associate Director of Nursing (Ms DiNapoli), The Institute for Advanced Medicine, Mount Sinai Health System; and Senior Administrative Director (Ms O_Flaherty), Patient Care Services Surgical Nursing, Lenox Hill Hospital, New York, New York; Elizabeth Brooks Ford Professor of Nursing (Dr Fitzpatrick) and The Marvin E. and Ruth Durr Denekas Professor of Nursing (Dr Musil), Francis Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio; Senior Vice President and Chief Clinical Officer (Dr Clavelle), HonorHealth, Scottsdale, Arizona. The authors declare no conflicts of interest. Correspondence: Ms DiNapoli, Mount Sinai Health System, 17 E 102nd St, Box 1009 New York, NY 10029 (Jean.dinapoli@ mountsinai.org). DOI: 10.1097/NNA.0000000000000302
The complexity of the healthcare system today challenges hospitals to provide safe, patient-centered, and cost-effective care. Economic constraints, changes in payment structures, the shift to value-based care, and increased emphasis on prevention are important forces in care delivery. Studies have shown that nurses who perceive their work environments as empowering have increased job satisfaction1 and increased patient satisfaction,2 provide higher quality of care,3,4 have better patient outcomes,5 and are more engaged.3,4,6-8 Kanter_s9 theory of structural empowerment (SE) has been widely applied in nursing research and practice. Kanter defined SE as the ability to get things done in an organization by having access to information, resources, opportunity, and support. Kanter acknowledged that management plays a significant role in the provision of these structural factors and posited that empowered leaders are more effective in empowering their employees, resulting in an increased commitment to ensuring the organizational goals are achieved.9 In addition to structural components, psychological empowerment is the emotional investment needed for staff to be successful.10 The process of psychological empowerment is influenced by the employee_s work environment and is demonstrated in 4 core concepts: meaning, competence, self-determination, and impact. Spreitzer10 further discussed that positive relationships can be seen between the core concepts of structural
JONA Vol. 46, No. 2 February 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
95
and psychological empowerment and its influence on empowering behaviors. The encouragement of an empowering environment fosters an individual_s perception of competence and selfefficacy, which provides them with the confidence to believe that they are able to meet the demands of the job. Spreitzer10 suggests that an environment that has a solid foundation of the structural and psychological core concepts alone does not necessarily promote an empowered staff. It is important that the individual is engaged and understands that their work has impact and is meaningful. Wang and Liu_s8 study explored the relationships among professional nursing practice, psychological empowerment, and nurse work engagement. The results of their study showed a significant relationship among these factors and provided a more complete understanding of how professional practice influences nurse engagement. Work engagement has been defined as a positive, fulfilling, work-related state of mind that is characterized by vigor, dedication, and absorption.11 Staff who are engaged enjoy going to work, feel valued, and relish the work that they do. Jenaro et al12 determined from their research that improvements in social and communication skills are needed for nurses to experience vigor and dedication, attributes of work engagement. Bakker et al13 hypothesized that employees are more likely to be engaged when their organizations provide a supportive, inclusive, and challenging environment that supports employees_ psychological needs. The management literature provides evidence for the relationship of workplace empowerment and employee engagement, but there has been minimal nursing research linking these variables. Laschinger et al4 were the 1st to examine the impact of empowering work environments on nurses_ work engagement and effectiveness. They highlighted the role of empowerment in promoting work engagement and effectiveness. Havens et al14 found nurses were more engaged when they felt their work environments promoted professional nursing practice. Other studies have shown positive work environments and staff engagement and empowerment are related to lower nurse turnover, increased autonomy, shared governance,15 and interdisciplinary teamwork.11,16,17 However, few studies have examined the relationships between perceptions of empowerment and engagement on the unit. Therefore, the purpose of this study was to describe relationships between SE, psychological empowerment, and engagement on the unit, among clinical nurses.
Methods Design and Research Questions The study used a national sample and a descriptive correlational design. The research questions were as follows:
96
What are the relationships between clinical
nurses_ SE, psychological empowerment, and engagement? How do clinical nurses_ background characteristics, SE, and psychological empowerment affect engagement? Sample A sample of RNs was obtained from the National Association of Orthopedic Nursing annual conference attendees in May 2014. Three hundred fifty participants completed the survey, with a final sample of 280; those who did not meet the following inclusion criteria were excluded. Inclusion criteria for this study were RNs with at least 1 year of experience on their unit and practicing full time in an acute care setting. RNs who worked part time or were in a leadership role, advanced practice nurses, or nurses who have worked on their unit for less than 1 year were excluded. Institutional review board approval was granted by Case Western Reserve University. Instruments Structural empowerment was measured with the Conditions of Work Effectiveness Questionnaire II (CWEQ-II),18 which consists of 19 items that measure the 6 components of SE described by Kanter (opportunity, information, support, resources, formal power, and informal power). A total empowerment score is obtained by summing the 6 subscale total scores, ranging from 6 to 30. Higher scores represent stronger perceptions of working in an empowered environment. Cronbach_s ! coefficients for the CWEQ-II subscales have been reported to range from .78 to .93.17 In the present study, Cronbach_s !_s ranged from .81 to .91 for the subscales, .92 for the total score. Psychological empowerment was measured using the Psychological Empowerment Instrument (PEI),10 a 12-item questionnaire with 4 dimensions: meaning, competence, self-determination, and impact. Each component is measured on a 7-point Likert scale, and total empowerment scores are obtained by averaging the total subscale scores. Higher scores represent higher levels of perceived psychological empowerment experienced at work. DeCicco et al19 reported ! coefficients ranging from .85 to .93, .85 for total score. In the present study, Cronbach_s !_s ranged from .85 to .91 for subscales, .91 for total score. Engagement was measured using the Utrecht Work Engagement Scale (UWES-9),20 a 9-item instrument that measures 3 components of work engagement: vigor (3 items), dedication (3 items), and absorption (3 items). These items are rated on a 7-point Likert scale ranging from never to always. Each subscale is averaged to
JONA Vol. 46, No. 2 February 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
produce a total scale score between 0 and 6, with higher scores representative of greater work engagement. The same process is used to obtain the total score. Schaufeli et al20 reported the Cronbach_s !_s varying from .89 to .97 (median, .93). In the present study, Cronbach_s !_s ranged from .75 to .84 for subscale scores, .91 for total score. A background questionnaire was used to collect data on age, gender, race, and ethnicity. Participants were also asked how many years they have worked as a nurse, which shift they work (12-hour day/night vs 8-hour day/evening/night or another shift), the highest degree achieved (diploma, associate degree, baccalaureate degree, master_s degree, or doctorate degree), if they hold a certification in nursing, and if they work at a Magnet -designated institution. A
Data Analysis Frequency distributions were used to describe the percentage of responses to the demographic variables of age, gender, race, ethnicity, years as a nurse, shift worked, certification status, highest degree achieved, and hospital_s Magnet status. Measures of central tendency, range, and SD were obtained to describe each demographic variable. Correlational analyses were used to answer the 1st research question. Multiple regression analysis was used to determine relationships between the demographic factors of age, ethnicity (Hispanic vs non-Hispanic), years as a nurse, shift worked (12- vs 8-hour shift), and structural and psychological empowerment with engagement.
Results The majority of participants were female (93.6%) and white (75.4%), with an average age of 44 years. They held a bachelor_s degree (60.0%) and had a certification in nursing (71.8%) (Table 1). Overall, nurses perceived their work environments as highly structurally empowering (mean, 23.33 [SD, 3.60]). Nurses perceived they had access to opportunity (mean, 4.23 [SD, 0.67]) and informal power (mean, 4.14 [SD, 0.72]). Access to resources was the lowest of the 6 subscales. The scores on psychological empowerment indicated that nurses were highly empowered with a mean of 5.61 (SD, 0.8). Nurses felt their work had meaning to the organization (mean, 6.04 [SD, 1.0]) but only moderate impact on the organizations outcomes (mean, 5.02 [SD, 1.20]). The clinical nurses in this study perceived themselves to be moderately engaged (mean, 4.76 [SD, 0.81]), with absorption having the highest subscore (mean, 5.03 [SD, 0.77]). The means and SDs of the major
Table 1. Demographic Data n Age
Minimum Maximum Mean
279
Gender
Male Female Transgender Race Alaskan or Native American Asian Black/African American Mixed race Native Hawaiian/ Pacific Islander White Other Total Ethnicity Hispanic or Latino Non-Hispanic or non-Latino Other Total Shift Day 12 h Night 12 h Day 8 h Evening/night 8 h Other Total Certified Yes No Years as RN
n 276
Degree
23
75
n
%
17 262 1 3
6.1 93.6 0.3 1.1
40 13
14.3 4.6
5 3
1.8 1.1
211 3 278 8 190
75.4 1.1
42 240 126 39 81 10 24 280 201 79
15.0
44
2.9 67.9
45 13.9 28.9 3.6 8.6 71.8 28.2
Minimum Maximum Mean 1
54
n
%
Diploma 11 Associate degree 61 Baccalaureate degree 168 Master_s degree 40 Magnet Yes 125 No 150
17.3
3.9 21.8 60.0 14.3 44.6 53.6
study variables and subscales of each instrument are presented in Table 2. Correlations Between Structural Empowerment, Psychological Empowerment, and Engagement To determine the relationships between the clinical nurses_ SE, psychological empowerment, and engagement, the Pearson correlation coefficients were examined. There was a moderate, positive correlation between total scores of SE and psychological empowerment (r = 0.40, P < .001). Additional analysis of the data revealed low to moderate, positive correlations between the majority of the subscales. Analysis of the relationships between SE, psychological empowerment, and engagement revealed moderate and positive correlations. There was a positive relationship between the overall SE score and
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Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
97
Table 2. Descriptive Statistics of Major Study Variables
CWEQ-II Opportunity Information Support Resources Formal power Informal power Total empowerment PEI Competence Meaning Impact Self-determination Total psychological empowerment UWES Vigor Dedication Absorption Total engagement
Mean
SD
Cronbach_s !
4.23 3.96 3.98 3.32 3.67 4.14 23.33
0.67 0.87 0.84 0.87 0.88 0.72 3.60
.81 .90 .91 .85 .85 .81 .92
5.92 6.04 5.02 5.45 5.61
0.99 1.00 1.20 1.18 0.87
.85 .91 .89 .88 .91
4.58 4.68 5.03 4.76
0.95 0.99 0.77 0.81
.84 .81 .75 .91
engagement (r = 0.43, P < .001). There was a positive moderate correlation between total scores of psychological empowerment and engagement (r = 0.31, P < .001). For research question 2, a hierarchical multiple regression analysis was conducted to evaluate the influence of structural and psychological empowerment and the background variables of ethnicity, shift, years as an RN, and age on engagement. Structural empowerment and age were the only variables shown to significantly predict engagement; older age and greater SE predicted more engagement and accounted for 27% (adjusted R2) of the variance in engagement.
Discussion This study is the first to evaluate the relationships between nursing SE, psychological empowerment, and engagement. The results reflected nurses feeling highly empowered and engaged and showed positive correlations between SE, psychological empowerment and engagement. Access to resources was scored the lowest in the domain of SE, which is consistent with results from previous empowerment studies1,21 and not surprisingly considering our current healthcare environment where resources are often limited because of factors ranging from financial restrictions to staff availability. The psychological empowerment dimensions, meaning, and competence yielded the most significant subscales scores. Yet the correlations between these scores with the dimensions of SE were low and often not significant. This could be indicative
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of the nurses feeling their work is meaningful and important, and they have the knowledge and skill set to render quality patient care regardless of their work environment. The positive relationship between psychological empowerment and engagement is consistent with previous studies.1,8 Conversely, the high level of competence reported and its lack of significant correlation with engagement could be indicative of the reported level of specialty certifications that these nurses have achieved, which leads us to believe that they are confident in their ability to provide care, regardless of their level of engagement. The positive relationship seen between the overall SE score with engagement is consistent with previous studies.4,7 Staff empowerment is necessary in creating positive work environments leading to job satisfaction and decreased turnover.3,6,22 These results are consistent with Wang and Liu_s8 and Leiter and Laschinger_s23 studies and further support the perception that empowering and supportive work environments have staff who are more likely to be engaged. In addition, results of this study revealed high empowerment scores, which have differed from results in previous studies. This may be indicative of our sample population of nurses who are attending a national conference, have baccalaureate degrees, and have specialty certifications. Analysis of background data showed the full-time nurses in our study perceived themselves to have more access to information, resources, opportunity, and support, therefore increasing their engagement on the unit. The information gleaned from the multiple regression analysis provides us with data that support the expectation that empowering work environments influence engagement of the nursing staff. Surprisingly, the results did not reflect a significant difference in engagement on the unit between nurses working 8-hour shifts versus those working 12-hour shifts. Although this has not been previously reported, it was thought that there would be a significant difference. Another surprising result not seen was the lack of a significant relationship between nurses working in a Magnet environment and engagement on the unit.
Limitations Limitations with this study could be associated with the design and sampling methodology utilized. Results might be affected by the convenience sample of participants attending a conference.
Future Implications for Nurse Leaders Results from this study have shown the logical expectation that empowering work environments foster
JONA Vol. 46, No. 2 February 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
staff engagement. Therefore, the value nurses attribute to their work environment and the relationships between empowerment and engagement is one that nurse leaders need to embrace. Nurse managers play a key role in developing an empowering work environment by facilitating the tools needed for support, guidance, and influencing positive change.24 They are responsible for maintaining high-quality care and job satisfaction, in an environment that often lacks human and financial resources.25 Competing priorities and additional responsibilities add a layer of complexity to the nurse manager_s role, with the push to do more with less; it can be a challenge to foster and create an empowering work environment. They must consider the relationship between SE, psychological empowerment, and engagement, when designing any change that may be necessary to meet the complexity of the healthcare system today. Our past practices may no longer be aligned with the switch to both value and evidence-based care. Successful organizations will be challenged to do more with less, and nurses being the largest discipline providing direct patient care are in a strategic position. Nurses who are empowered and engaged will be more likely to accept and thrive in this new environ-
ment than nurses who are not. Passionate, empowered, and engaged clinical nurses are often the informal leaders, have considerable influence, seek advanced degrees and/or certifications, and pursue a career path that builds upon their experience, thus affording professional growth.
Conclusion This study has demonstrated the impact empowering work environments have on engagement. Nurses who are not engaged see their profession, leaders, and colleagues differently, and it will take a creative leadership approach to engage them, if at all. Work engagement is a motivational factor, which can lead to job satisfaction and lower turnover. Leaders can then focus their efforts to sustaining empowering work environments, and staff engagement can be harnessed to develop programs and initiatives that support quality care and move the profession forward. A strong relationship exists between empowerment and engagement, both essential in driving a high-performing work unit. Nurse leaders who lead a unit where nurses feel a strong sense of pride and are engaged in their work will see the benefits of quality patient care.
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