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Critical care nurses perceptions of

workplace empowerment, magnet


hospital traits and mental health

By Judy A. Tigert, ACNP, MScN CCN(C),


Renal Care, London Health Sciences Centre and
Heather K. Spence Laschinger, PhD, Professor and
Associate Director Nursing Research, School of Nursing
Health Sciences, Faculty of Health Sciences,
University of Western Ontario, London, Ontario.

Abstract

The purpose of this study was to test Kanters Theory (1977,


1993) of Structural Power in Organizations in a sample of
Canadian critical care nurses. A secondary analysis of data
from a larger descriptive correlational survey design was used
to examine the relationships between perceived empowerment,
perceived magnet hospital traits and critical care nurses
mental health (n = 75). The instruments in this study included
the Conditions for Work Effectiveness Questionnaire II, the
Job Activities Scale II, the Organizational Relationship Scale
II, the Nurses Work Index-Revised, the Emotional Exhaustion
Subscale, and the State of Mind Subscale.

Empowerment was significantly and positively related to


perceptions of magnet hospital traits (r = .49, p = 0.001). The
combination of empowerment and magnet hospital traits
explained a significant amount of the variance in mental
health indicators: burn-out (19%) and state of mind (12%).

Background and rationale

The Canadian Nurses Association predicts that Canada could


suffer a shortage of 78,000 nurses by the year 2011 (Fletcher,
2002). The work environment is one factor contributing to the
shortage. Sustaining nurses in specialty areas such as critical
care will be particularly challenging. Intensive care units are
fast-paced work environments with critically ill patients who
are attached to invasive technology while nurses tend to their
needs, monitor progress, troubleshoot alarms and comfort
grief-stricken families. These environments are stressful for
nurses (Bailey, Steffen & Grout, 1980). Measures must be
taken to support the health of critical care nurses so they will
choose to remain in the profession and continue to provide
quality care for the critically ill.

Studies on the effects of the work environment on nurses


attitudes and behaviours have consistently shown that job
satisfaction and turnover are related to autonomy, job strain,
and decisional involvement in the workplace (Havens &
Laschinger, 1997; Sabiston & Laschinger, 1995). Magnet
hospital work environments have been found to support the
professional practice of nursing and decrease nurse turnover
and burn-out (Aiken, Smith, & Lake, 1994).
One theory used to study the nursing work environment is
Kanters Theory of Structural Power in Organizations (Kanter,

CACCN

1977, 1993). Kanter contends that structural conditions in the


workplace that are empowering influence the employees
ability to accomplish work in a meaningful way which, in turn,
leads to feelings of job satisfaction and work effectiveness. It is
reasonable to expect that these empowering work environments
would support the professional practice behaviours that
characterize practice in magnet hospitals (nurse autonomy,
control over the practice setting and collaboration with
physicians). Moreover, both workplace empowerment and
magnet hospital characteristics have been linked to nurses
emotional health in the workplace (Laschinger & Havens,
1997; Aiken, Sloane & Klochinski, 1997).

The purpose of this study was to test a model derived from


Kanters theory linking critical care nurses perceptions of
workplace empowerment, perceptions of the presence of
magnet hospital traits in their work setting, to their perceived
mental health.

Theoretical framework

Kanters Theory of Structural Power


Kanter (1977, 1993) proposes that employee work effectiveness
is largely related to structural or situational aspects of the
organization. Kanter identified three empowerment structures in
organizations that have a personal impact on employee
behaviour and attitudes: (a) the structure of power, (b) the
structure of opportunity, and (c) proportion structures (social
composition of peer clusters). These structures in the work
environment affect employee work behaviour/attitudes more
than employee personality traits. Access to these structures is
influenced by the degree of formal and informal power held by
employees. Formal power is found in jobs that are visible,
central to the purpose of the organization and that allow for
discretion in decision-making. Informal power systems
(alliances) are relationships with supervisors, peers and
subordinates that enable (powerful) individuals to get things
done. The three sources of power are: (a) resources, (b)
information, and (c) support. Information refers to the data,
technical knowledge and expertise required to function
effectively and carry out the tasks required to perform ones job.
Resources refer to the money, materials, supplies and equipment
required to accomplish the goals at work. Support is the
feedback and guidance received from the supervisor, peers and
subordinates. Opportunity is the potential of advancing to
challenging positions or roles within the organization and the
extent to which the job allows the employee to gain skill while
being rewarded and recognized. Access to empowerment
structures results in increased motivation, autonomy, employee
decisional involvement, organizational commitment and job
satisfaction. Consequently, employees become more productive
and effective in meeting organizational goals.

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Review of the literature


Numerous nursing studies support Kanters contention that
workplace empowerment is associated with employee
involvement in decisions related to the content (autonomy)
and context of practice (participation in management
decision-making). Laschinger, Sabiston and Kutszcher
(1997) found that autonomy was significantly explained by
formal and informal power and access to workplace
empowerment structures. Nurses perceptions of
empowerment were also strongly related to their
perceptions of participative management. Several other
studies have linked empowerment to staff nurse decisional
involvement (Havens & Laschinger, 1997; Huffman 1995;
Laschinger & Havens 1997). Almost and Laschinger
(2002) found a significant positive relationship between
nurse
practitioners
perceptions
of
workplace
empowerment and collaboration with physicians. These
studies suggest that empowerment may be an important
determinant of magnet hospital characteristics (autonomy,
control over the practice setting, and collaboration with
physicians). Empowerment has also been negatively
associated with job stress and burn-out (Hatcher &
Laschinger, 1996; Laschinger & Havens, 1997;
Laschinger, Wong, McMahon & Kaufman, 1999;
Laschinger, Finegan, Shamian & Wilk, 2001).
In 1982, the American Academy of Nursing (AAN) recognized
hospitals that were supportive of the professional practice of
nursing and had no difficulties recruiting and retaining nurses.
These hospitals became known as magnet hospitals
characterized by work environments that fostered high levels
of nurse autonomy, nurse control over practice and
collaborative nurse-physician relationships (Kramer &
Schmalenberg, 1988; McClure, Poulin, Sovie & Wandelt,
1982). Magnet hospital designation continues to be a valued
accreditation in the United States today.

Burn-out is a frequently studied indicator of nurses mental


health. Work stress has frequently been associated with burnout in nursing staff (McCranie, Lambert & Lambert, 1987;
Robinson, Roth, Keim, Levenson, Flentje & Bashor, 1991).
Bailey, Steffen and Grout (1980) identified sources of stress in
the critical care setting. The top ranked job-stressors were: (a)
interpersonal conflict, (b) management of the unit, (c) nature
of direct patient care, (d) inadequate knowledge and skills, (e)
physical work environment, (f) life events, and (g) lack of
administrative rewards.

Gentry, Foster and Froehling (1972) found that critical care


nurses demonstrated significantly more depression,
resentment, irritability and verbal aggression than did noncritical care nurses. Lewis and Robinson (1992) found that
critical care nurse use of maladaptive coping measures (drugs
to relax, absenteeism, alcohol, overeating, smoking and
caffeine) were related to perceived stressors at work. IskraGolec, Folkard, Marek and Noworol (1996) found that ICU
nurses working 12-hour shifts experienced significantly more
burn-out, chronic fatigue, cognitive anxiety, and general sleep
disturbances than did nurses working eight-hour shifts.

Hypothesis

20

High levels of workplace empowerment and magnet hospital


traits in the work environment are positively related to critical
care nurses mental health.

Methods

Design and sample


The data for this study were drawn from the second wave of
a longitudinal study of nurses in Ontario, Canada (1998 and
2001). This study, a correlational survey design, examined the
relationships between critical care nurses perceptions of
workplace empowerment, magnet hospital traits in the
workplace, and nurse mental health. The original data set
consisted of 239 nurses who worked in Ontario teaching
hospitals. The nurses names were randomly selected from the
College of Nurses of Ontario (CNO). The overall return rate
for the second wave of data collection (2001) was 69.8 per
cent. There were no significant differences with regard to the
distribution of demographic characteristics or major study
variables between respondents in the first and second wave of
the study.
A subsample of 75 critical care nurses provided 80 per cent
power to detect a medium effect size, based on Cohens (1988)
conventions for regression of two independent variables.

Instruments
Research instruments are frequently evaluated by their
construct validity and internal consistency (reliability). A
widely used index of reliability is the Cronbachs reliability
coefficient. The normal range for the Cronbachs reliability
coefficient is between 0.00 and 1.00, with higher values
representing greater reliability (Polit & Hungler, 1999).

The Conditions for Work Effectiveness Questionnaire II


(CWEQ-II), The Job Activities Scale II (JAS-II), and the
Organizational Relationship Scale II (ORS-II) (Laschinger,
Finegan, Shamian & Wilk, 2001) measured empowerment. The
CWEQ-II has four subscales that measure perceived access to
empowerment structures: (a) opportunity, (b) information, (c)
support, and (d) resources. Items are rated on a five-point Likert
scale. Subscale mean scores are obtained by summing and
averaging items (range one to five) with high scores indicating
higher levels of perceived access to empowerment structures.

The construct validity of the CWEQ-II has been substantiated


by Laschinger, Finegan, Shamian, and Wilk (2000) in a
confirmatory factor analysis. The Cronbach reliability
coefficients for the CWEQ-II were: 0.81 (total), 0.82
(opportunity), 0.91 (information), 0.81 (support) and 0.81
(resources).
The Job Activities Scale (JAS-II), a three-item scale, measured
critical care nurses perceptions of formal power, that is
perceptions of discretion, visibility and recognition within the
work environment. The Cronbachs reliability coefficient for
the measurement of formal power (JAS II) was 0.75. The
ORS-II, a four-item scale, was used to measure perceptions of
informal power within the work environment. The Cronbachs
reliability coefficient for the ORS II was 0.65.
The NWI-R, a revision of the original Nursing Work Index
(NWI), was used to measure magnet hospital traits (Aiken &

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Patrician, 2000). The three NWI-R subscales used most


frequently in magnet hospital research (autonomy, control over
practice, and nurse-physician relationships) were also used in
this study. Items are rated on a four-point Likert scale.
Subscale mean scores were obtained by summing and
averaging items with high scores indicating higher levels of
autonomy, control over the practice environment and
collaboration with physicians. Cronbachs reliability
coefficients for the NWI-R subscales were: 0.86 (total), 0.71
(autonomy), 0.76 (control), and 0.88 (collaboration).

Mental health was measured using the five-item State of Mind


subscale (SOM) of the Pressure Management Indicator (PMI)
(Williams & Cooper, 1998) and by the six-item Emotional
Exhaustion (EE) subscale of the Maslach Burn-out Inventory
(MBI) (Maslach & Jackson, 1981). State of Mind was rated on
a six-point Likert scale (range one to 6). The Cronbachs
reliability coefficient for the SOM subscale was 0.78.
Emotional exhaustion was rated on a seven-point Likert scale
(range zero to six). The Cronbachs reliability coefficient for
the EE subscale was 0.89.
A brief questionnaire examined the demographic
characteristics of the participants (gender, age, years of work
experience, work status, years on unit, dependents under five
years of age, education level, overtime worked, occasions of
illness, and hospital type).

Data analysis and descriptive results


Descriptive and inferential statistics were computed using
SPSS Version 10 (SPSS, 2001). Demographic characteristics
of the participants are displayed in Table One. Reliability
analyses were conducted on all subscales used in the study.
The means and the standard deviations for the major study

variables are displayed in Table Two. There were no


significant relationships found between the major study
variables and demographic characteristics of the participants.

Tests of the hypothesis


As predicted, the combined effect of workplace empowerment
and magnet hospital traits was found to be significantly related
to critical care nurses perceptions of mental health. Nineteen
per cent of the variance in emotional exhaustion (EE) in
critical care nurses was explained by empowerment and
perceptions of magnet hospital traits (R2 = .19, F (2, 71) =
8.06, p = .001). However, only empowerment was a significant
independent predictor of EE (B = 0.33, t = - 2.7, p = .01). This
finding is consistent with a study that linked empowerment to
burn-out (Hatcher & Laschinger, 1996). Similarly, 12 per cent
of the variance in state of mind (SOM) was explained by the
combined effect of empowerment and perceptions of magnet
hospital traits (R2 = .12, F (2, 70) = 4.57, p = .02). Although
perception of magnet hospital traits was a significant predictor
of SOM (B = -.31, t = 2.4, p = .02), empowerment was not (B
= .06, t = 0.48, p = .63). The relationship between SOM and
magnet hospital traits has not been reported in previous
literature. These findings suggest that nurses are more likely to
experience less emotional exhaustion and higher levels of
mental health in hospitals that foster both empowerment and
professional nursing practice (magnet hospital traits).

Discussion

The findings of this study lend further support to Kanters


propositions (1977, 1993) that access to empowerment
structures is associated with positive employee outcomes, in
this case, employee mental health. Consistent with theoretical
predictions, higher levels of empowerment were associated

Table One: Sample descriptive statistics


Age (years)
Years experience in nursing
Years on present unit

Education
Hospital diploma
Community college diploma
BScN
MscN
Other
Total

Gender
Male
Female
Total

N
71
75
74

Frequency
12
45
11
1
6
75

Frequency
41
34
75

Minimum
32.00
2.00
1.00

Per cent
16.0
60.0
14.7
1.3
8.0
1.00

Per cent
54.7
45.3
100.0

Marital Status

Frequency

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Single
Married/cohabiting
Separated/divorced
Widowed
Total

13
57
4
1
75

Per cent
17.3
76.0
5.3
1.3
100.0

Maximum
61.00
38.00
35.00

Mean
43.9437
19.6467
11.6149

Standard
Deviation
5.83313
7.16399
6.26282

Valid Per cent Cumulative Per cent


16.0
16.0
60.0
76.0
14.7
90.7
1.3
92.0
8.0
100.0
100.0

Valid Per cent Cumulative Per cent


54.7
54.7
45.3
100.0
100.0

Valid Per cent Cumulative Per cent


17.3
76.0
5.3
1.3
100.0

17.3.
93.3
98.7
100.0

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with greater autonomy, control over the practice environment


and nurse-physician collaboration in critical care settings. This
study also provides empirical evidence for the link between
Kanters concept of empowerment and magnet hospital traits
in critical care settings.

Critical care nurses did not perceive themselves to be highly


empowered. These results are consistent with the findings of
Baguley (1999). In this study of Canadian critical care nurses,
levels of autonomy, collaborative relations with physicians and
control over the practice setting were lower than those found
in American magnet hospitals (Aiken, Havens & Sloane,
2000). This suggests that there is room for improvement in
Canadian nursing work environments. The moderately high
levels of nurse-physician collaboration reported by critical
care nurses were similar to those in a study of Canadian Nurse
Practitioners (Almost & Laschinger, 2002). This is not
surprising given that both groups have advanced skills and
work in close proximity with physicians.

Both empowerment and perceptions of magnet hospital traits


were significantly related to mental health. Empowerment was
a stronger predictor of emotional exhaustion while perceived
magnet hospital traits predicted state of mind more strongly.
These findings suggest that both empowerment and perceptions
of magnet hospital traits are predictive of positive employee
mental health, although each affects different domains of
mental health. These findings are consistent with previous
research (Laschinger, Finegan, Shamian, & Wilk, 2001;
Laschinger & Havens, 1997) and further support Kanters
(1977, 1993) contention that access to empowerment structures
in the workplace can decrease job stress and positively
influence employee mental health. The results of this study will
be discussed as they apply to critical care nurses and managers.

Implications for critical care nurses


Critical care nurses must proactively examine their work
environment, assess the health risk, and collaborate with their
managers and colleagues to create environments conducive to
healthy working conditions. Kanters (1997, 1993) theory

provides strategies for creating such environments. This can be


accomplished by active participation of nurses in committees
that influence nursing practice and by working collaboratively
with physicians and peers. It would be advantageous for
critical care nurses to become familiar with guidelines
advocated by the Magnet Services Recognition Program
(1999) by participating in professional organizations and
conference planning committees that could arrange conference
speakers from magnet hospital organizations.

Implications for critical care nurse managers


In todays fiscally constrained health care setting, critical care
nurse managers are challenged to contain costs, reduce
absenteeism, minimize adverse outcomes and enhance patient
satisfaction. The nurse manager today must be cognizant of
evidence-based predictors of organizational effectiveness such
as work empowerment. With the growing body of evidence to
support Kanters theory, it behooves the nurse manager to
become very familiar with the strategies implied by the theory.
The nurse manager must strive to empower the nursing staff
through provision of information, support, resources and
opportunities. As evidenced by this study, nurse managers who
incorporate these aspects into nursing work environments are
likely to create work environments where nurse autonomy
exists, where nurses have control over the practice setting, and
where nurse-physician collaboration thrives.
The Magnet Services Recognition Program (1999) is also
essential for nurse managers. It is with this practical knowledge
that managers can develop the processes and systems in their
own organizations that will enhance nurse autonomy, control
over practice and collaborative nurse-physician relationships.
The findings of this study support the importance of magnet
hospital-like working conditions with respect to nurses health
and suggest that there is work to be done to improve critical
care work environments in Ontario. Given the impending
nursing shortage in Canada, nurse administrators must make
every effort to ensure that the work environment supports
nurses ability to practise according to professional standards,
thereby reducing stress and increasing satisfaction.

Table Two: Observed means and standard deviations for instrument scales and subscales
Instrument

Overall Empowerment (Total CWEQ II)


Sum of 6 Empowerment Scales
Subscales:
Opportunity
Information
Support
Resources
Formal Power
Informal Power

Nursing Work Index-Revised Total Score


Autonomy
Control Over Practice
Collaboration with Physicians

Mental Health Indicators


Emotional Exhaustion Subscale
State of Mind Subscale

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Score Range

Mean

SD

75

6 - 30

17.66

3.24

74
74
74
74

1-4
1-4
1-4
1-4

2.63
2.47
2.52
2.90

0.48
0.56
0.57
0.65

75
74

0-6
1-6

3.10
4.42

1.29
0.91

75
75
75
75
75
75

1-5
1-5
1-5
1-5
1-5
1-5

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3.90
2.78
2.54
2.74
2.30
3.4

0.73
0.93
0.88
0.84
0.86
0.69

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Limitations

The limitations of this study are related to both the design and
the methods used. Due to the correlational design of the study,
causal relationships cannot be inferred. Response bias is
always a concern with the use of self-report questionnaires
(Polit & Hungler, 1999). Critical care nurses who responded to
the survey may have been intrinsically more empowered and
may have experienced better levels of health than those who
did not respond. Another limitation of the study is the
sampling process used to acquire subjects. Critical care nurses
may have been missing from the CNO registry list, because
they may have refused to allow the CNO to release their names
for research purposes. The fact that the sample was selected in
the province of Ontario prevents generalization to other
Canadian nurses.

Acknowledgement

The authors would like to acknowledge CACCN for providing


funding for this research project.

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