Nurse Empowerment from a Middle-Management Perspective: Nurse Managers’ and Assistant Nurse Managers’ Workplace Empowerment Views
Loretta C Regan, RN, MS; Lori Rodriguez, RN, PhD
Winter 2011 - Volume 15 Number 1
Background: Researchers have explored empowerment as an important condition for nursing staff but little current research focuses on empowerment from a middle-management perspective.
Aims and Objectives: The purpose of this study was to assess the empowerment of a middle-management group made up of only nurse managers (NMs) and assistant nurse managers (ANMs) in an acute-care hospital setting.
Methods: A questionnaire was distributed online to a convenience sample of NMs (n = 11) and ANMs (n = 31) working in an ethnically diverse acute-care hospital.
Results: Overall, this middle-management group did not feel empowered.
Conclusions: Empowerment as perceived by middle management is crucial for carrying out leadership duties and, in turn, empowering frontline staff. Even though the work is challenging, resources and support, among other constructs of empowerment, must be improved to increase the empowerment of middle management. Nursing administration must understand the importance of an empowered middle management so that middle management can lead effectively and facilitate the delivery of safe, high-quality patient care.
Nurse managers (NMs) and assistant nurse managers (ANMs) play an essential role in creating an empowering work environment for their staff. Empowerment is defined as the ability to get things done and includes a capacity to mobilize resources and to provide support, opportunity, and information.1,2 Additionally, for NMs and ANMs to be able to empower others, management must provide access to resources. The organizational power structure itself must be identified, because it can affect perceptions of empowerment at all levels.3 In practice, a leader must have a sense of empowerment in order to empower others. The literature contains extensive information on empowering the nurse at the bedside and frequently points to the first-line manager as the person to provide empowerment for the staff nurse. However, little is known about how NMs and ANMs themselves are empowered and experience empowerment in their roles.
NMs and ANMs are the frontline leaders for nursing staff in acute-care hospitals. NMs and ANMs make up the middle layer of leadership between nursing administration and staff nurses. Their role involves communication with staff, patients, and members of the interdisciplinary health care team.4 The middle manager handles an immense amount of responsibility, such as the hiring and firing of staff, judging competency of staff, assuming budgetary responsibility, and taking overall responsibility for the delivery of safe, high-quality patient care.2,5 Further, NMs and ANMs are responsible to the service-line Director and Chief Nursing Officer in most acute-care hospitals. Creating an environment that ensures the delivery of safe and high-quality patient care, high patient satisfaction rates, and positive patient outcomes is also the responsibility of NMs and ANMs. In addition, they are required to implement policy changes that are often driven by regulatory agencies, such as state health departments and the Joint Commission.
Block emphasized that "as managers, our task is to empower ourselves and to create conditions under which others can do the same."6 A health care culture that values growth and input from frontline staff requires an empowered leader who facilitates the delivery of safe, high-quality patient care.2 However, if a middle manager does not feel empowered, how can s/he be expected to create conditions that will empower others? We explored how NMs and ANMs, also referred to as middle managers, perceive their own empowerment. Given their multiple responsibilities and the fact that empowerment contributes to getting a job done, it is important to assess NMs' and ANMs' perceptions of empowerment.
We used Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PubMed to conduct a literature review, searching on the following phrases: staff nurse empowerment, NM and ANM empowerment, and nurse engagement and job satisfaction. We found a scarcity of information specific to understanding how NMs and ANMs experience empowerment in the hospital setting. Nevertheless, a literature review conducted by Lee and Cummings7 found that organizational support within the institution was a significant contributing factor in empowerment. This is consistent with the organizational theory described by Kanter,8 an expert in the field of organizational behavior.
The literature revealed extensive research on empowerment and its importance as experienced by employees. Stichler9 examined ways in which staff nurse engagement could affect operations within a facility and concluded that empowerment of employees enhanced the sustainability of change. Change is, of course, a constant in health care, and sustainability is a major area of importance. Therefore, researchers have worked to better understand the ways in which different groups of workers perceive empowerment from a multidisciplinary perspective. Currently, the full range of the consequences of empowerment in the nursing profession is not fully understood. However, findings from the Institute of Medicine reveal that a likely value of the empowerment of nurses is the promotion of safe patient care and improved patient outcomes.10
A study of the nurse's role in quality improvement found that an effective nursing staff delivered improved patient care as measured by improved patient outcomes.11 Empowerment is important at most levels of health care delivery. Just as staff nurses do, nurse educators who feel engaged, effective, and valued experience empowerment that allows them to be effective in staff development and to make decisions quickly on the job. Johnson also found that empowered nurse educators demonstrated greater flexibility in adapting to ongoing change.12 Similar characteristics were found among staff nurses who expressed a feeling of empowerment in their work.13
Laschinger et al14–18 have conducted extensive research on the empowerment of nursing staff and on leadership's ability to instill empowerment. Of particular interest here is work by Laschinger et al19,20 that used Kanter's organizational theory as a foundation for clarifying the ways in which empowerment is understood and maintained by nursing staff, as well as how it is used effectively by nursing leaders. Another study by Laschinger et al,21 conducted in an acute-care setting, demonstrated that effective leadership is a source of empowerment for staff.
McDermott et al22 found that organizational commitment is important particularly when human and economic resources are limited and when a high quality of nursing care must be maintained. Excellence in nursing may be successfully cultivated by finding new ways for NMs to empower their staff.
Safety in the hospital environment is of primary concern for leaders, health care providers, patients, and their families. Working conditions within the hospital setting are often influenced by environmental and human concerns. Empowerment of nurses with regard to their work environment is recognized as an important factor in acquiring the desirable status of magnet hospital from the American Nurses Credentialing Center.23 Moreover; nursing leadership strives to identify ways to improve patient outcomes. In the acute-care clinical setting, empowerment of nurses can be key to such improvement.15
Faulkner and Laschinger24 found that empowerment within the context of structural and psychological parameters was a significant factor in the delivery of high-quality health care. Their data showed a positive correlation between improved care and nurses' feelings of being respected, as well as between improved care and nurses' levels of self-respect.
A study of nurses found that job satisfaction and reduced job stress can be two of the positive consequences of promoting nurse empowerment and can serve to reduce nurse burnout.18 Enhancing hospital nurses' experience of empowerment may stem the growing shortage of experienced nurses.25 A workforce is more likely sustainable when staff nurses trust and respect their direct managers. Unhealthy work environments, where nurses are emotionally drained and feel overwhelmed, are more likely to be settings that risk patient safety.26 Nurses who feel empowered in their role express confidence, and successful NMs who can empower their staff serve an important role in creating a healthy and safe work environment.27
The literature shows a gap in the understanding of the empowerment of direct NMs and ANMs in the clinical setting. Therefore, we explored how NMs and ANMs experience empowerment.
The conceptual framework that guided our research was based on organizational empowerment, as described by Kanter,1,8 and psychological empowerment, as described by Conger and Kanungo.3
Kanter's theory on organizational empowerment is composed of four components that are imperative to promoting structural empowerment. Access to resources and information28 and the skill to fulfill role expectations make it possible to achieve more and to pass on more to subordinates. Employees who believe that their manager can get things done are more likely than those who do not believe in their manager's abilities to come together as a high-functioning team.8 Kanter's theory provides both a framework for exploring empowerment and moves toward developing interventions to improve work environments so that they will ultimately offer more meaningful work. Kanter1 described organizational empowerment as necessary for providing opportunity and power in companies for optimal staff effectiveness and achievement. Theoretically, staff respond effectively to work environments in which they feel empowered. The organizational benefit is manifested in better staff attitudes and increased efficiency. Empowerment is possible when employees have access to information, support, resources, and the chance to discover and develop. Kanter's components of empowerment are as follows1,8:
- Ability to advance in a current role or the opportunity to be involved in activities beyond the current scope of practice
- Access to information that allows staff to fulfill role expectations and understanding of the proper source from which to obtain correct information
- Knowledge of job expectations and support in fulfilling them
- Ability to obtain resources required to accomplish tasks.
Psychological empowerment, as described by Conger and Kanungo,3 is a motivational state that is based partially on Bandura's theory of self-efficacy. That theory proposes that those who believe that they will succeed have a greater chance of doing so than do those who do not hold that belief.29 Conger and Kanungo explained empowerment as a process that begins with the elimination of barriers that prevent staff from feeling the power needed to accomplish their work.30 Empowered staff are more likely than nonempowered employees to start behaving in ways that maintain professionalism even in challenging environments, and this increases work effectiveness.3 Psychological empowerment is the emotional investment that staff need for empowerment to be successful.30
Organizational empowerment and psychological empowerment are the key components of employee empowerment.24 Staff nurses report to NMs and ANMs, who must be empowered to fulfill their role as leaders so that staff nurses can in turn fulfill their role in acute-care hospitals. Given the dynamic role of NMs and ANMs in an extremely complex health care system, we used this conceptual framework as a guide to study empowerment from the perspectives of NMs and ANMs.
We aimed to explore how NMs and ANMs experience workplace empowerment in their role as middle managers in the acute-care hospital setting. Given the very complexity of health care, NMs and ANMs must be empowered to perform leadership roles.4 NMs and ANMs must be able to persuade staff that they are empowered to facilitate positive patient outcomes.13 Empowerment is the ability to get a job done well with the necessary information and equipment to accomplish the work.28 We focused on the perception of empowerment: How do NMs and ANMs perceive their sense of empowerment in an organizational setting—in particular, in an acute-care hospital? Their perceptions, if positive, can facilitate empowerment of staff nurses, allowing delivery of safe, high-quality patient care.
Ours was a nonexperimental quantitative, cross-sectional, descriptive survey designed to measure organizational empowerment among NMs and ANMs in a 327-bed private teaching hospital accredited by the Joint Commission. The hospital was opened in August 2007. It is located in an ethnically diverse metropolitan area. The Nurse Work Empowerment Scale, also referred to as the Conditions of Work Effectiveness Questionnaire II (CWEQ-II), was distributed to a convenience sample of 49 NMs and ANMs from all of the clinical units in the hospital; all participants were employed by the hospital during the research and were at least 18 years old. All members of middle management in the hospital were eligible to participate.
Approval for the study was obtained from both the Kaiser Permanente (KP) Northern California Institutional Review Board and the institutional review board of the university in our service area. The data were collected through Survey Monkey (www.surveymonkey.com). We obtained permission to use the CWEQ-II from Heather Laschinger-Spence, MD.31 We sent an e-mail to all participants that outlined the purpose of the study, explained that respondents would remain anonymous, and invited participants to complete an online survey.
The Research Instrument
We used the CWEQ-II, which has been applied primarily in research aimed at frontline nurses, to survey NMs and ANMs. The CWEQ-II also includes the Job Activity Scale II (JAS-II) and the Organizational Relationship Scale II (ORS-II). The CWEQ-II consists of 19 items that measure opportunity, information, support, resources, formal power, and informal power; these are the components of organizational empowerment as described by Kanter.8 A two-item global empowerment scale is included for construct-validation purposes. Scores for items on each of the six subscales are summed and averaged to provide a score for each subscale, on a Likert scale ranging from 1 to 5. A score of 5 on the Likert scale represents the highest level of agreement; 1 indicates none—the strongest level of disagreement. The scores of the six subscales are then summed to create the total empowerment score (score range, 6–30). Higher scores represent higher perceptions of empowerment.
The two global empowerment items are summed and averaged to create a score ranging from 1 to 5. This score is not included in the structural empowerment score. The correlation between this score and the total structural empowerment score provides evidence of construct validity for the structural empowerment measure.
The CWEQ-II questionnaire was completed by 11 NMs and 31 ANMs; this represents an 86% response rate. The NMs' ages ranged from 46 to 50 years; 73% were female. The ANMs were slightly younger, with an age range of 36 to 40 years; 81% were female. In the two groups, 36% of the NMs reported having one to three years of management experience and 36% as having four to six years in management. Nearly 84% of ANMs reported having less than three years' experience in a management role.
The CWEQ-II demonstrated a Cronbach alpha of 0.91 for organizational empowerment. Table 1 shows subscale scores by role.
We performed an independent two-tailed t-test for each of the subscales and for the total CWEQ-II as well as the JAS-II and ORS-II used for construct validity. The Cronbach alpha was 0.05 for all statistical testing. There were no statistically significant differences in the perceived organizational empowerment for the NMs versus ANMs for any of the subscales, for global empowerment, or for total empowerment.
When asked about the amount of opportunity that middle managers believed they had in their job, half (50%) reported that their work was challenging, about half (45%) reported that their work gave them a chance to gain new skills and knowledge, and fewer than half (41%) reported that their work used all of their skills (Table 2). Less than 49% of participants reported that they had sufficient access to information from top management regarding the state of the hospital, values, and leadership's goals. Some access to support was evident: 38% reported receiving information about things done well, 52% reported receiving specific comments about things that they could improve, and 57% reported receiving helpful hints or problem-solving advice. The largest percentage of respondents (38%–57%) reported that they lacked access to the support they needed to do their job as managers. Many respondents (36%–38%) reported that they lacked resources to meet their managerial job requirements. Only 36% reported that temporary help was readily available when needed.
Fifty-one percent of respondents reported, on the JAS-II, that they believed that there were rewards for innovation on the job. Less than 46% reported that their job allowed flexibility, but half (50%) reported that they had visibility for work-related activities. Fifty percent of respondents reported, on the ORS-II, that they collaborated with physicians on patient care. Less than half (48%) reported being sought out by peers for help with problems, and 48% reported being sought out by managers for help with their problems. Only 41% reported that they were sought out for advice by other professionals, such as dietitians or physical therapists, on a multidisciplinary team.
On the two-item global empowerment subscale used for construct validity, which was not used for the total empowerment score, less than half (45%) of respondents reported that their current work environment empowered them to accomplish work in an effective manner and only 37% considered the workplace to be an empowering environment (Figure 1). The mean score for total empowerment was 21 (SD = 2.91) for NMs and 20 (SD = 3.36) for ANMs, revealing a lack of empowerment felt by this group of middle managers (Table 1).
CWEQ-II = Conditions of Work Effectiveness Questionnaire II.
CWEQ-II = Conditions of Work Effectiveness Questionnaire II.
Figure 1. Two-item global empowerment subscale of the Conditions
of Work Effectiveness Questionnaire II. This subscale was used only
for construct validation, and its scores were not included in the total
Our findings indicate that NMs and ANMs who are relatively inexperienced in management lack the information, support, and resources necessary to accomplish required work. Lee and Cummings7 found that the amount of perceived organizational support significantly contributes to a perception of empowerment. We found that middle managers perceived a lack of organizational support. Both empowerment theory and the literature on organizational support point to a possible negative impact of such a perception on staff development and even patient safety.
Our findings also reveal that empowerment of NMs and ANMs, which is a required characteristic for those who are leaders in a complex health care environment,4 is lacking. As McDermott et al22 noted, middle managers must feel empowered if they are expected to empower their staff and thus achieve excellence in nursing. To empower middle managers, leadership must pay attention to those empowerment constructs that are often perceived as minor, such as providing adequate time and support to do a job.
We found that although some middle managers feel some empowerment in their work, managers with less experience particularly need additional support and resources. Suggestions on how to empower middle managers can be gleaned from the research tool itself. To increase empowerment, nursing administrators must take the lead in breaking down barriers to success by providing necessary resources, improving communication, and displaying support.
A significant limitation of our study is that its findings were from a single medical center. Because empowerment is strongly linked to organizational culture,22 exploring the sense of empowerment at one facility informs about that facility. Because of the high response rate for our survey, our findings are informative about the setting; however, they may not be generalizable to other settings. Another limitation of our study was its small sample size.
Our study serves as a pilot study for better understanding the ways in which NMs and ANMs in a hospital setting perceive empowerment and how empowerment influences their role perception, satisfaction, and ability to carry out their varied responsibilities as middle managers. NMs and ANMs with less experience in a leadership role may have more difficulty feeling empowered, especially when key elements are not provided. The next step for research at this facility would be to determine what behaviors and actions from upper management increase empowerment in middle managers. The work that has been done at magnet hospitals, although focused largely on empowerment of staff, may provide further insight into empowering behaviors for managers. If empowerment of middle managers is the desired outcome, then middle managers must work collaboratively with upper management to make their needs known and design reasonable and affordable ways to reach this desired outcome. Failing to empower middle management will lead to retention difficulties at both the management and staff level and will ultimately impair the delivery of safe patient care.
The author(s) have no conflicts of interest to disclose.
Katharine O'Moore-Klopf, ELS, of KOK Edit provided editorial assistance.
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