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Evaluating Physical Therapists' Perception of Empowerment Using Kanter's Theory of Structural Power in Organizations

1. Patricia A Miller, 2. Peggy Goddard and 3. Heather K Spence Laschinger + Author Affiliations 1. PA Miller, PT, MHSc, is Assistant Clinical Professor, School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada. At the time of the study, she was Profession Leader, Physiotherapy, Hamilton Health Sciences Corporation, Hamilton, Ontario, Canada. Address all correspondence to Ms Miller at 5 Undercliffe Ave, Hamilton, Ontario, Canada L8P 3G9 (pmiller@mcmaster.ca) 2. P Goddard, MScN, RN, is Assistant Clinical Professor, School of Nursing, McMaster University. At the time of the study, she was Chief of Professional Practice and Chief Nursing Officer, Hamilton Health Sciences Corporation 3. HK Spence Laschinger, PhD, RN, is Associate Director, Research, and Professor, School of Nursing, University of Western Ontario, London, Ontario, Canada Next Section

Background and Purpose. Little is known about physical therapists' perceptions of empowerment. In this study, Kanter's theory of structural power in organizations was used to examine physical therapists' perceptions of empowerment in a large Canadian urban teaching hospital. Kanter's theory, which has been studied extensively in the nursing profession, proposes that power in organizations is derived from access to information, support, resources, opportunity, and proportions. Subjects and Methods. A convenience sample of physical therapists who had been working in the hospital longer than 3 months was used to determine the scores for the physical therapists' ratings of empowerment using the Conditions of Work Effectiveness Questionnaire. Results. Physical th Physical therapists' scores were higher than the majority of reported staff nurses' and T

score and the physical therapists' global rating of empowerment. Unlike studies of nurses, there were no relationships when demographic attributes and empowerment scores were examined. Discussion and Conclusion. Evidence for the validity of Kanter's theory of empowerment was found. Kanter's theory can provide physical therapists and their managers with a useful framework for examining critical organizational factors (access to information, support, opportunity, and resources) that contribute to employees' perceptions of empowerment. A baseline measure for comparing future empowerment scores of this sample is available. Further work to examine the application of Kanter's theory to other samples of physical therapists appears to be warranted.

Empowerment Kanter's theory of structural power in organizations Organizational restructuring Program management

The definition, implementation, and integration of empowerment concepts is said by at x 1(p18) in health care organizations. A T k that speaks to values that facilitate the employees' choice to invest in and own personal actions and behaviors resulting in positive contributions to the organization's 1(p19) She suggested that the empowerment of staff is a critical factor in an organization's achievement of its mission, vision, and strategic directions, particularly in the face of organizational change. According to Rosabeth Moss Kanter,2 work environments that empower are those in which access to information, support, and resources necessary to accomplish work is available, as well as those that provide opportunities for growth and development of knowledge and skills.3 Kanter's theory of structural power in organizations2 can provide a framework for the examination of the organizational structures within work environments. The Figure provides a model of Kanter's theory. The theory, in our view, can help individuals gain insight into strategies that might empower workers so that they will be more successful in contributing to organizational goals. Kanter's theory has been studied extensively as it relates to the profession of nursing,319 but the theoretical framework has not been investigated in any other group of health care professionals. Our study was undertaken to examine the applicability of Kanter's theory to the profession of physical therapy using a sample of physical therapists in a large urban teaching hospital in Ontario, Canada.

Theoretical Framework
In her book, Men and Women of the Corporation,2 Kanter stated that power in organizations is derived from structural conditions in the work environment, not from an individual's personal characteristics or socialization effects. Power is the ability of

individuals to get things done and is derived from the position that a person occupies in the organization.2 This theory of power evolved from Kanter's ethnographic study of work environments in a large American corporation.2 According to Kanter's theory, power is derived from formal and informal sources of power. Formal power, according to Kanter, is found in jobs that are visible and central to the purpose of the organization and that allow for discretion in decision making. In addition to high-profile job activities, individuals derive power from the alliances they form within the organization with superiors and peers, as well as with subordinates.2 These alliances are thought to provide informal sources of power that enable individuals to get the cooperation they need to get things done.2 Kanter maintained that the individual with a high degree of access to formal and informal power has increased access to opportunity and power through the organizational structure.4 According to Kanter, individuals with power and opportunity feel empowered and are happy and productive at work. She contended that such workers are able to contribute to activities that address the organizational goals. Kanter2 described 3 organizational structures that influence work behaviors in organizations: power, opportunity, and proportions. The structure of opportunity relates to job conditions that provide individuals with opportunities to advance within the organization and to advance their knowledge and skills. Kanter maintained that opportunity is a key influence on employee work satisfaction and productivity. The structure of proportions refers to the social composition of peer clusters (eg, sex, race).2 For the purpose of this study, the influence of proportions was not examined. Kanter20 contended there are 3 structural organizational sources of power: access to lines of information, support, and resources. To be empowered, according to Kanter's theory, people need to access knowledge and information necessary to carry out their jobs. This includes information directly related to their own work, as well as information about the organization as a whole. Support can be derived from feedback and guidance received from superiors, peers, and subordinates. Access to resources for employees means there is an ability to obtain material, money, and rewards necessary for achieving the demands of the job. According to Kanter,2 when people do not have access to information, support, resources, and opportunity, they feel powerless. Those with access to power and opportunity, according to Kanter's theory, are highly motivated and are able to contribute to the development of an empowering environment by sharing their sources of power. Considerable support for the validity of Kanter's theory has been established in the nursing profession, where perceptions of empowerment of both staff nurses and nurse managers have been examined in a variety of organizations, ranging from large acute care teaching facilities to small community hospitals.4 Nurse empowerment has been found to be related to the nurses' organizational commitment,59 burnout,10 work satisfaction,11 immediate manager's leadership style,12 level in the hierarchy,1316 and autonomy.17 Given that Kanter's theory attempts to address the workplace conditions of women and that nursing and physical therapy are 2 professions with high proportions of women, this theory may be particularly appropriate for examining the work of both of these health

care professions.4 The purpose of our study was to examine the theory's applicability to the profession of physical therapy using a sample of physical therapists in a large, urban teaching hospital. The objectives were: (1) to determine physical therapists' perceptions of workplace empowerment using 3 instruments based on Kanter's theory, (2) to seek evidence of the construct validity of Kanter's theory in the physical therapist population by examining the relationship between the physical therapists' perceptions of empowerment and their global rating of empowerment, (3) to test proposed relationships among personal and employment factors within the physical therapist population, namely the relationship between empowerment and access to structures from which formal and informal power are derived according to Kanter's theory, and (4) to examine relationships between perceptions of workplace empowerment and demographic factors of the physical therapists. Three instruments that had been used previously to measure Kanter's power constructs4 were used to evaluate the physical therapists' perceptions of total empowerment, access to formal power, and access to informal power.
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Sample and Setting

Using a sample of convenience, all physical therapists (N=75) employed in a large urban teaching hospital for greater than 3 months were asked to complete and return a survey questionnaire. The questionnaire was obtained from the principal investigator (HKSL) of the Work Empowerment Research Program at the School of Nursing, University of Western Ontario, London, Ontario, Canada (Web address: www.uwo.ca/fhs/nursing/laschinger/). This study was undertaken in the fall of 1997, just 1 year after two 2-site hospitals merged to create a large 4-site organization. This large urban teaching hospital with 1,400 beds provides acute care services at 3 of the 4 sites and offers rehabilitation and long-term care services at the fourth site. All 4 sites are within the central Canadian province of Ontario. The patient services provided by the organization include acute medicine and surgery, as well as pediatrics, trauma, and rehabilitation services. Both former hospitals had been in the process of adopting program management for at least a year prior to the merger, and a partial program management design21 was adopted by the new organization. Staff members such as physical therapists and nurses have been organized into discipline-specific departments and have been managed by members of their own discipline. In what we are referring to as program management, there is a shift away from the differentiation by function, and the emphasis is meant to be placed on programs that are created to address the needs of a given patient population.21 Accordingly, when the functional departments are eliminated, physical therapists are deployed from the physical therapy department, and they become part of the multidisciplinary team in a

program. There is a great deal or variation in organizational designs, and varying levels of integration of the clinical and functional services occur.21 In a partial program management design, for example, some departments remain unchanged and offer service to all programs in the organization, while the staff in other departments are deployed.21 Organizational mergers and restructuring, including the adoption of program management, has been a common occurrence in both Canadian and American health care facilites.21 In the program management environment, decision making is intended to be decentralized to frontline staff members and the program managers.21 Program managers are intended to have full accountability for the fiscal and human resources of the program. Benefits claimed for program management include a greater realization of the multidisciplinary team approach, better resource allocation in a client-centered manner, and increased staff commitment to a program.21 Data to support this claim, however, have not been published in a peer-reviewed format. In addition, there are proposed to be improvements in the decision-making process as frontline health care professionals assume responsibility to deal with program-related issues.22 With the establishment of the new organizational structure, the majority of departments, including that of physical therapy, were eliminated. Physical therapists, nurses, occupational therapists, social workers, and other health care professionals were assigned to one or more programs when their respective departments were disbanded. The pharmacy department, however, remained a centralized service. Physicians were aligned with a specific program or programs where they were expected to function as part of the multidisciplinary team. Each program identified a management role for one physician (medical director) who collaborated with the program director on administrative issues. The physical therapists were deployed to 15 of the 19 new clinical programs. In the majority of instances, the physical therapist worked alongside other physical therapists on the unit in the program. There were, however, instances where the physical therapist was the lone therapist in a program or where the physical therapist was responsible for the care of patients in more than one program. As part of the interdisciplinary team in the program, the staff physical therapist became directly accountable to the program director, who in all except 2 programs was a health care professional from a discipline other than physical therapy. All physical therapists who had been in leadership positions in the former organiza therapists who had both administrative and clinical responsibilities, physical therapist education coordinator) assumed staff physical therapist positions or left their physical therapy role to assume other roles in the restructured organization. Following the merger, the physical therapists established a professional practice committee that consisted of 10 staff members representing physical therapists and physical therapist assistants from all sites. A profession leader was selected by the staff to monitor and promote the standards of practice. The professional practice committee met monthly, and the profession leader circulated the minutes of the meeting and other relevant information. The profession leader represented the physical therapists on the

hospital's professional advisory committee where 23 profession leaders met monthly to discuss professional practice issues that crossed programs and disciplines.

The Conditions of Work Effectiveness Questionnaire (CWEQ) was created by Kanter2 and adapted by Chandler23 to test Kanter's theory in a nursing population. The CWEQ can be used to determine a total empowerment score. The CWEQ consists of 42 items divided into 4 subscales. These subscales measure perceived access to sources of jobrelated empowerment, namely: (1) information, (2) support, (3) resources, and (4) opportunity. Respondents are asked to rate each of the 42 items on a 5-point Likert scale T subscale scores ranging from 1 to 5, and then the 4 subscale scores are added to give a total empowerment score ranging from 4 to 20. Higher scores reflect higher levels of empowerment. Recent studies examining the internal consistency of these subscales yielded the following range of Cronbach alpha reliability coefficients: .73 to .97 for information, .72 to .91 for support, .66 to .88 for resources, and .73 to .91 for opportunity.4,6,7,15 Reliability data for the measurements, however, is lacking. The Job Activities Scale (JAS) and the Organizational Relationships Scale (ORS)18 were developed based on Kanter's descriptions of formal and informal power, respectively. The JAS measures access to formal power structures. High scores represent job activities that give high formal or position power. The ORS measures access to informal power structures. High scores represent a strong network of alliances in the organization or high informal power. The JAS consists 12 questions, and the ORS consists of 19 questions. Respondents are asked to rate items on a 5Lk T score for each measure is determined by summing and averaging items to yield a score ranging from 1 to 5. The higher the scores on the JAS and the ORS, the more access to formal and informal power structures, respectively. The internal consistency of these instruments, as determined using Cronbach alpha reliability coefficients, have been acceptable, ranging from .64 to .72 for the JAS and from .88 to .95 for the ORS.4 Reliability of these measurements, however, is not known. The physical therapists' global rating of empowerment was calculated using the mean of 2 items that each used a 5Lk k T q : O y current work environment empowers me to accomplish my k O I k 4 T q Minor modifications to the wording of the original questionnaire items were made to make the terminology appropriate for the program management environment. For z D

q z
Data Collection

T k

unit/clinic is used to describe the area within the

The questionnaire, along with a cover letter and return envelope, was mailed to each participant through the inter-hospital mail system. The cover letter provided a brief explanation of the study, assuring anonymity and confidentiality of participants. After 2 weeks, a reminder notice was sent to all physical therapists via the inter-hospital electronic mail system. Completed questionnaires were returned by inter-hospital mail and were collected by a secretary. Return of the completed questionnaire constituted the subject's consent to participate. Data were collected over an 8-week period.
Description of Subjects

Sixty-five physical therapists (87%) returned completed questionnaires. Eighty-eight percent of the respondents were female, and 12% were male. Eighty-two percent of the respondents were employed full-time; 78% had a baccalaureate degree. The average years of professional experience was 12.7 years (range=less than 1 year to 35 years). Forty percent of the physical therapists were employed in more than one program. Sixtytwo percent of the physical therapists had been members of the national professional association within the previous 2 years, and 77% had participated in activities in the undergraduate physical therapist program at the local university such as tutoring or teaching clinical skills.
Statistical Analyses

Mean CWEQ, JAS, and ORS scores were calculated. The relationship between the total empowerment score (CWEQ) and the global rating of empowerment was examined using Pearson correlation analyses. The relationship between the scores for formal and informal power (JAS and ORS, respectively) and total empowerment (CWEQ) were examined using regression analysis. Relationships among empowerment scores and demographic variables were examined using Pearson correlation analyses and tests for differences among group means. Internal consistency reliability analyses were performed on all empowerment scales.
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Table 1 shows the mean total empowerment score the 4 CWEQ subscales addressing physical therapists' perceptions of access to information, support, opportunity, and resources. The mean scores related to access to formal power (JAS) and informal power (ORS) were 2.81 (SD=0.40, range=2.084.00)

and 3.29 (SD=0.60, range=2.164.58), respectively. Both formal power (JAS) and informal power (ORS) scores were moderately related to the physical therapists' total empowerment scores (r=.49, P=.000 and r=.42, P=.001. respectively).
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Table 1.

Conditions of Work Effectiveness Questionnaire (CWEQ) Scores for Empowerment Variables for Physical Therapists in the Study Sample (n=65) Both formal power (JAS) and informal power (ORS) scores contributed independently to the prediction of the total empowerment score, combining to explain 57.2% of the variance (R2=.572, df=2.60, P=.001). The total empowerment score was correlated with the physical therapists' global rating of empowerment (r=.40, P=.001). There were no relationships between the total empowerment score and any of the demographic variables, including sex, years of practice, and level of education, whether the therapist worked in more than one program or whether the therapist was active in professional or academic activities (Tab. 2).
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Table 2.

Relationships Between Empowerment Scores and Demographics of Physical Therapists in the Study Sample (n=65) The internal consistency for these instruments, as examined using Cronbach alpha reliability coefficients, were similar to those found in previous studies of nurses4: 4 JAS ORS
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Discussion and Implications

The physical therapists perceived that they had a moderate degree of job-related empowerment, as measured by the CWEQ, and the results are similar to scores of staff nurses obtained in previous research.4 For example, in a study examining perceptions of empowerment and managerial self-efficacy,16 the mean CWEQ score for 109 full-time staff nurses in a metropolitan teaching hospital in the same province was 11.65, compared with 11.67 in our sample. Because we contend that nurses and physical therapists in staff positions are positioned at similar levels in the organizational hierarchy, we would anticipate access to workplace empowerment structures. We believe this is particularly true in program management, where the health care professionals are expected to assume responsibility and collaborate as team members in providing patient care. Both perceptions of formal and informal power were found to be equally important predictors of physical therapists' empowerment. This finding supports our belief that physical therapists recognize the need to develop effective relationships with other health care professionals within the program management environment (informal power) and the need to be viewed as contributing to program or organizational goals (formal power). These results support the use of Kanter's model, where access to formal and informal power sources is related to access to work empowerment structures. These results are similar to the results found in studies of nurses.4 T ORS for nurses in both staff and management positions.4 For example, the mean ORS scores in 2 samples of staff nurses in a large acute care teaching hospitals in a metropolitan area were 3.0617 and 3.25.19 The questions on the ORS measure perceptions of informal power and examine interactions with the physician, immediate supervisor, peers, and other health care professionals. Physical therapists value the multidisciplinary team approach, and interdisciplinary communication is an integral part of providing physical therapist services in a hospital. Many of the physical therapists' goals are believed to be achieved more quickly when there is assistance from other team members. The team's ultimate goal, we believe, is to improve the patient's health and functional independence, and physical therapists play an integral role in this process. The high ORS score suggests that the physical therapists are health care providers who provide and receive information from many individuals in their work area and that they see themselves, and are viewed by others, as an integral part of the team. Further research is necessary to determine whether there are differences among different health care professionals' in their ability to access empowerment structures within the same organization. This is the first time that Kanter's theory has been examined in a program management environment, and the impact of program management on staff members' perception of empowerment has yet to be determined. When staff members are deployed from a traditional department to a program, certain conditions could arise that could reduce their access to empowerment structures, but data are yet available to confirm or refute this premise. Physical therapists' access to professional information is reduced with the

disbanding of the professional network, and their access to support from professionspecific resources or peers, in our view, may also be affected. This may be especially pronounced if they are the sole physical therapist in a program. Their access to financial resources to support educational activities or purchase equipment may be limited as the program resources are shared by the entire team. Opportunities to advance professional knowledge may be reduced if discipline-specific leadership positions (eg, physical therapy researcher) are not retained. Furthermore, access to structures from which formal power can be derived may be eliminated if all professional leadership positions are removed when physical therapists assume staff positions in programs. A program management environment, however, may also create situations where staff members would have increased access to structures that lead to increased perceptions of empowerment. Although access to profession-specific information may be affected, access to program-specific and patient-specific information should be improved. Structures that facilitate access to informal power may also be improved with a more coordinated team approach. Our findings (ORS scores) may reflect this. Our study was the first study in which the CWEQ was used by staff members in a program management environment. Further research is warranted to better understand the ways that staff members access empowerment structures in program management and to better understand the impact of organizational restructuring on empowerment structures. Unlike previous studies of nurses, no relationships were demonstrated between staff perception of empowerment and demographic factors, such as years of experience or levels of education. Our results could be due to a number of factors, including sample size. For example, studies of nurses have shown higher CWEQ scores for those higher in the organization's hierarchy in accordance with Kanter's theory.14 This construct is difficult to assess in an organization with program management because often the profession-specific management positions are eliminated with the deployment of staff members to programs. It was not possible to conduct this analysis in our sample because the physical therapist in the managerial position as the profession leader was one of the authors (PAM). Our results provide previously unavailable information relating to physical therapists' perceptions of workplace empowerment. The correlation of the total empowerment score (CWEQ) with the global rating of empowerment provides evidence of support for the validity of Kanter's theory in this population. Taken together, these analyses provide support for Kanter's theory in the hospital-based physical therapist population and extend its applicability beyond nursing to other health care professions.

The use of a sample from one organization limits the generalizability of the results to other physical therapist populations. Fewer physical therapists are working in the traditional hospital setting.24,25 According to the 1997 Canadian Alliance of Physiotherapy Regulators' Human Resource Survey,24 the number of physical therapists practicing in publicly funded hospitals in Ontario, Canada, was similar to the number in

private practice in the community, with approximately 40% of active practitioners in each setting. Chevan and Chevan25 reported a similar shift toward greater employment in community settings in the United States as well. The theoretical constructs of Kanter's theory have been examined in settings other than hospitals. Haugh and Lashinger15 examined the perceptions of empowerment of public health nurses and their managers who worked in community-based settings. The results suggest that the application of Kanter's theory can extend to both community and hospital settings. Therefore, physical therapists working in settings other than hospitals might consider the application of Kanter's theory to their own work environments, but research in those settings is needed. We believe that caution must be used when comparing the results of our study with the results of studies of nurses. Ours was the first study of physical therapists' perception of empowerment in a program management environment. Our results may differ from those from studies of nurses not only because of the professional culture differences, but also because of organizational restructuring.
Future Research

Further research is warranted in other samples of physical therapists and in other groups of health care professionals. There has been only one study26 of the perceptions of empowerment of multidisciplinary team members involved in preparation for hospital accreditation, where physicians, physical therapists, nurses, and other health care professionals comprised the teams. Further research examining perceptions of empowerment in other teams and disciplines appears to be warranted. Studies to replicate those conducted in the nursing profession in which empowerment was found to be related to other factors such as organizational commitment9,11 and autonomy19 should be undertaken among physical therapy staff and other professional groups.
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Support for Kanter's theory was found in our sample of physical therapists. Further research to examine the applicability of Kanter's theory in other samples of physical therapists appears to be warranted. Kanter's theory provides a theoretical framework for the understanding and investigation of empowerment within organizations. The theory can provide physical therapists and their managers with useful information about the sources of empowerment that exist in an organization. By considering organizational structures that provide access to information, support, resources, opportunity, and formal and informal power, we argue that therapists can better understand ways to become empowered.
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All authors provided concept/research design, writing, and consultation (including review of manuscript before submission). Ms Miller provided data collection and analysis, project management, and fund procurement. The authors acknowledge the statistical consultation offered by Kevin Eva and the assistance with the data entry and literature review that was provided by Heather Loeffen and Meera Pancholi, who were students in the Physiotherapy Programme at McMaster University. Ethical approval for research involving staff questionnaires was not required by the Ethical Review Board of Hamilton Health Sciences Corporation. This research was supported by a grant from the Hamilton Civic Hospitals Foundation, Hamilton, Ontario, Canada. This material was adapted from presentations given at the Ontario Physiotherapy Association Conference, March 26, 1999, Hamilton, Ontario, Canada, and at the 13th International Congress of the World Confederation for Physical Therapy, May 24, 1999, Yokohama, Japan.

Received May 3, 2000. Accepted May 14, 2001. Physical Therapy

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