Secondary Logo

Journal Logo

Articles

Nursing Empowerment

How Job Performance Is Affected by a Structurally Empowered Work Environment

Ta'an, Wafa'a F. PhD, RN; Alhurani, Jumanah MScN, RN; Alhalal, Eman PhD, RN; Al-Dwaikat, Tariq N. PhD, RN, CHPE; Al-Faouri, Ibrahim PhD, RN

Author Information
JONA: The Journal of Nursing Administration: December 2020 - Volume 50 - Issue 12 - p 635-641
doi: 10.1097/NNA.0000000000000951
  • Free

Abstract

Empowerment is defined as the decentralization of authority.1 Empowered staff members display improved autonomy and an awareness of their role in the accomplishment of organizational goals. Empowerment can be divided into 2 categories: psychological and structural. Psychological empowerment occurs when individuals have a sense of motivation regarding their workplace environment.2,3 Structural empowerment is prominent in administrative processes and helps in improving workers' involvement in their relationships, resulting in enhanced job satisfaction and performance.4,5 Administrators can modify the work environments to implement the principles of structural empowerment; however, psychological empowerment comes from the staff themselves. The World Health Organization stresses the importance of providing quality healthcare services, which can be attained by high-quality healthcare workers.6 It is important to support the nursing staff to achieve high standards of health outcomes around the world.7 Therefore, this study is important because nurse leaders need to improve working environments to engage new nurses and decrease avoidable turnover.8

According to Kanter's9 theory, the importance of structural empowerment can be derived from access to 4 organizational sources: information, support, resources, and opportunity, and through formal and informal power. Structural empowerment is realized when nurses feel powerful in their work settings. It is considered a component in the new Magnet® model.10 The Magnet model consists of 5 components: transformational leadership, exemplary professional practice, structural empowerment, empirical outcomes, and new knowledge, innovation, and improvement.10 Structural empowerment is an important concept that affects nurses' work environments as it affects the availability and accessibility of resources. It has become a progressively significant factor in deciding burnout, performance, and job satisfaction.11,12

The current healthcare system is experiencing increased challenges due to patient acuity and the advancement of technology. Thus, we need to maximize the performance of workers. Job performance is defined as the commitment to standards while working.13 It is also referred to as the method and procedure, which represents how nurses provide care for their patients.14 Healthcare institutions across the globe are striving to enhance the quality of care and improve patients' outcomes and satisfaction. This can be achieved by having the right workforce become key players in achieving institutional goals and performing their jobs in more effective manners. The performance of nurses is substantial because they are the largest group of workers in most of the healthcare institutions and spend the most time with their patients. Therefore, nurses play a significant role in organizational achievement of goals in healthcare settings.

No previous studies have investigated the levels of structural empowerment and its relationship to nurses' job performance. Structural empowerment varies across entities and cultures according to the structure of their respective healthcare institutions. Most of the previous studies, mainly conducted in Western countries, investigated the concept of “support,” which is 1 component of structural empowerment. A literature review on nurses' empowerment recommended further investigation of structural empowerment among nurses in Jordan.15 The purpose of this study is to investigate the level of structural empowerment among nurses and to explore the relationship between structural empowerment and job performance among nurses in Jordan.

Methods

A cross-sectional descriptive design was applied in this study. The study took place in Jordan, which is a low- to middle-income country that has migrants from Arab countries affected by war resulting in an increased demand for quality healthcare.16 The study was conducted in 4 hospitals—a university hospital, a not-for-profit hospital, a governmental hospital, and a private hospital, in order to enhance generalizability and to compare the 4 healthcare sectors in Jordan. Hospitals were selected as part of a convenience sample based on bed capacity, the number of RNs, and accessibility.

The study adopted convenience sampling techniques. The minimum sample size required was 180 based on a power of 0.8 and level of significance P = .05 with moderate effect size, according to Cohen's17 table for statistical analysis and sample size. However, sample size was increased to 200 participants in order to avoid participants' attrition. The participants were selected as part of a convenience sample according to their availability in the hospitals at the time of data collection.

Any RN with a bachelor's degree in nursing or a postgraduate degree, with a full-time employment, who had been working in their current position for at least 6 months as a direct patient care nurse, was eligible to be a participant. The following were excluded as respondents: nurses in administrative positions, those in infection control or quality assurance departments, and those who were in part-time status. Nurses who hold degree lower than bachelor, such as LPNs, were excluded because we were looking to have a representative sample of nursing workforce in Jordan, and there are limited numbers of LPNs in Jordan.

Structural empowerment was measured using the Conditions for Workplace Effectiveness II Questionnaire (CWEQ II), which was developed by Laschinger et al18,19 in 2001. The CWEQ II was designed based on the Kanter theory and consists of 21 items distributed on 6 subscales measured on a 5-point Likert scale. The subscales are as follows: opportunity, access to information, support (access to support), resources, formal power, and organization relationships. The Cronbach's α's for these subscales were .81, .80, .89, .84, .69, and .67, respectively), and the Cronbach α for the total scale was .89.19 The total structural empowerment is calculated by summing all these subscales. For the total scores of CWEQ II, values from 6 to 13, 14 to 22, and 23 to 30 represent low, moderate, and high levels of structural empowerment, respectively.

The Six-Dimension Scale of Nursing Performance

The Six-Dimension Scale of Nursing Performance, developed by Schwirian20 in 1978, was used in this study to measure job performance of nurses; it consists of 6 subscales and 52 items. The subscales are leadership, critical care, teaching/collaboration, planning/evaluation, interpersonal relations/communications, and professional development. Cronbach's α's for these subscales ranged from .84 to .97.20 In this study, we aimed to investigate the quality of job performance. The scale starts with the question, “How well does this nurse perform these activities in his/her current job?” followed by the subscales' items (eg, “promote the inclusion of patient's decision and desires concerning his/her care”). The items can be answered on a 4-point scale (1 = not very well, 2 = satisfactory, 3 = well, and 4 = very well). The total job performance score is calculated by taking the mean of the items for each subscale.

An approval to use, translate, and modify the tools was obtained by the authors. Standard translation procedures were used for the previous instruments. Data collection started after approvals were obtained from the institutional review board at Jordan University of Science and Technology Deanship of Research, as well as the hospitals' administrators. Data were collected between December 2018 and April 2019. Research purposes and information were explained to nurses. Nurses were assured that anonymity and confidentiality will be preserved and that they can withdraw from the study at any time. Nurses who met the inclusion criteria and voluntarily agreed to participate were given envelopes containing the cover letter that included an information sheet about the study, consent form, and the study questionnaires. Participants were asked to sign the consent forms, complete the questionnaires, and return them to the data collector upon completion. Participants' completed questionnaires were coded, and consent forms and demographic questionnaires were kept in a locked cabinet in the principal investigator's office.

Data were analyzed using SPSS for Windows, version 23 (Armonk, New York). Descriptive statistics were used to describe the characteristics of the respondents and to identify the scores of structural empowerment and job performance among them. The Mann-Whitney U test was used instead of an independent-samples t test when the assumptions of the independent-samples t test were violated. Pearson product moment correlation was also used to examine the relationships between continuous demographic variables (age, experience, income, weekly working hours, and the number of assigned patients), and the scores of structural empowerment and job performance.

Results

A total of 195 nurses completed the study including 88 males (45.1%) and 107 females (54.9%). The response rate was 97.5% of total 200 possible respondents. As presented in Table 1, the mean age of the participants was 28.42 (SD, 4.54) years. The mean number of assigned patients was 6.78 (SD, 5.73). The mean years of experience was 5.46 (SD, 3.86). Half of the participants were married (n = 50.3%, n = 98). Most participants (71.8%, n = 140) have a monthly income of 600 JD or less (US $846). Most of the participants have a bachelor's degree in nursing (89.7%, n = 175), and the remainder (10.3%, n = 20) had master's degrees.

Table 1 - Sociodemographic Characteristics of Participants
Variable Frequency Percent Mean SD
Age 28.42 4.54
Experience 5.46 3.86
Weekly working hours 44.95 4.97
Assigned patients 6.78 5.73
Gender Male 88 45.1
Female 107 54.9
Marital status Single 92 47.2
Married 98 50.3
Divorced or widow 5 2.6
Hospital Public 50 25.6
Teaching 46 23.6
Private 49 25.1
Non-for-profit 50 25.6
Income <400 JD (US $564) 25 12.8
400-600 JD (US $564-846) 115 59.0
>600 (US $846) 55 28.2
Shift α A, B, C 67 34.4
A 16 8.2
A, B, C, or AB 53 27.2
Day, night 59 30.3
Education BSc 175 89.7
MSN 20 10.3
Unit Medical/surgical units 67 34.4
Critical care units 64 32.8
Pediatric unit 27 13.8
Emergency department 22 11.3
Others (gynecology units, palliative unit, endoscopy, dialysis) 15 7.7
αFor shift: A, days; B, evening; and C, nights.

Table 2 presents the structural empowerment and job performance scores. Overall, nurses in this study perceived their work environment to be moderately empowering (mean, 18.99; SD, 5.06). Participants believed that they had greatest empowerment in relation to informal power (mean, 3.33; SD, 0.85) and least empowerment in relation to formal power (mean, 2.91; SD, 1.06). The mean total score of Six-Dimension Scale of Nursing Performance was 140.26 (SD, 40.43) (range, 58-206), and the mean score for all of the 52 items was 2.70 (SD, 0.78) (range, 1.12-3.96). The mean scores of the subscales were as follows: interpersonal relations and communication (mean, 2.71; SD, 0.85), leadership (mean, 2.73; SD, 0.79), critical care (mean, 2.81; SD, 0.80), teaching and collaboration (mean, 2.61; SD, 0.84), planning and evaluation (mean, 2.70; SD, 0.91), and professional development (mean = 2.69; SD, 0.79).

Table 2 - Nurses' Perception of Structural Empowerment and Job Performance
Min Max Mean SD
Structural empowerment
 Opportunity 1.00 5.00 3.23 1.10
 Resources 1.00 5.00 3.20 .82
 Information 1.00 5.00 3.15 .902
 Support 1.00 5.00 3.16 .93
 Formal power 1.00 5.00 2.91 1.06
 Informal power 1.00 5.00 3.33 0.85
 Total structural empowerment 6.00 27.75 18.99 5.06
 Global empowerment 1.00 5.00 3.12 1.07
Job Performance
 Communications 0.85 2.71 3.92 1.00
 Leadership 0.79 2.73 4.00 1.20
 Critical care 0.80 2.81 4.00 1.29
 Teaching and collaboration 0.84 2.61 4.00 1.00
 Planning and evaluation 0.91 2.70 4.00 1.00
 Professional development 0.79 2.69 4.00 1.10
 Mean job performance 0.78 2.70 3.96 1.12
 Total job performance 40.43 140.26 206.00 58.00

Data analysis revealed that structural empowerment was significantly and positively associated with income (r = 0.326, P < .01) and working hours (r = 0.564, P < .01), whereas there was a significant negative relationship between structural empowerment and age (r = −0.343, P < .01), experience (r = −0.284, P < .01), and number of assigned patients (r = −0.634, P < .01). The analysis showed that job performance was significantly and positively associated with income (r = 0.322, P < .01) and working hours (r = 0.629, P < .01), whereas there was a significant negative relationship between job performance and age (r = −0.349, P < .01), experience (r = −0.287, P < .01), and number of assigned patients (r = −0.594, P < .01).

Pearson correlation coefficient was calculated to identify the strength and direction of the relationship between structural empowerment and each subscale and the total score of nursing job performance, and the results are shown in Table 3. The score of structural empowerment demonstrated a significant positive correlation with the overall job performance (r = 0.928, P < .01).

Table 3 - The Relationship Between Structural Empowerment and Job Performance
Relationship/
Communication
Leadership Critical Care Teaching/
Collaboration
Planning/
Evaluation
Professional
Development
Total
Performance
R 0.885a 0.860a 0.831a 0.901a 0.883a 0.825a 0.928a
aP < .01.

Table 4 presents the results of the Mann-Whitney U test, indicating a statistically significant difference in the scores of structural empowerment and job performance between the specialized and nonspecialized hospitals. Specialized hospitals are those that provide a limited range of services to diagnosis-related patient groups. The specialized hospitals were found to have better scores on structural empowerment and job performance compared with nonspecialized hospitals (P < .01). Additionally, in the results of Mann-Whitney U test, nurses working on fixed shifts were found to have better scores of structural empowerment and job performance compared with nurses working on rotating shifts (P < .01). However, there was no significant difference in the scores of structural empowerment and job performance based on the area of specialty of the participants.

Table 4 - Differences in the Level of Structural Empowerment and Job Performance Between Hospitals, Working Shift, and Working Area
Variable Structural Empowerment
Mean Rank
P Job Performance
Mean Rank
P
Hospital type Nonspecialized 73.19 <.001 170.5 <.001
Specialized 169.96 73
Working shift Fixed shift 141.23 <.001 143.89 <.001
Rotating shift 70.98 69.32
Type of work unit General units 100.61 .263 102.02 .486
Critical care units 94.70 92.91

Discussion

Respondents reported performing their jobs well. The results revealed that the job performance for each dimension and overall score were at a moderate level. This finding is congruent with another study conducted in Jordanian private, governmental, and university hospitals.21 The other interesting finding is the significantly positive relationship between structural empowerment and working hours. This result is consistent with a previous study that found that nurses who work for more hours feel a higher level of empowerment compared with those working fewer hours.22 This may be because of increased continuity of care among these nurses, and hence, they are more acquainted with the situation of their patients and institutions.

A significant negative relationship was noted between structural empowerment and the number of assigned patients. The lower number of assigned patients decreases the workload, which, in turn, allows nurses to have both the opportunity and time to be and feel empowered, to share their opinions, and to participate in institutional activities. When a nurse is assigned to a number of patients that is more than the recommended standard ratio, it can result in errors affecting patients' safety and quality of care due to heavy workload, as well as the nurses' feeling of accomplishment.

The analysis revealed that job performance was both significantly and positively associated with income. This can be interpreted by the motivational effects of high salaries. It results in increasing the quality of care and level of job performance. This result is consistent with the results of a previous study that found a positive relationship between salary and job performance.23 Another study found that income had a positive impact on staff performance.24

The current study revealed a significant positive relationship between structural empowerment and overall job performance. This means that the highly empowered staff members perform better than the less empowered ones. A previous study found a significant positive relationship between structural empowerment and organizational performance.25 Additionally, this study revealed a statistically significant difference in the mean level of structural empowerment and job performance between the specialized and nonspecialized hospitals. The specialized hospitals were found to have better scores as compared with the nonspecialized hospitals in this regard. There are no previous studies that directly mention the difference in the level of structural empowerment and job performance based on the type of hospitals. However, Keuter et al26 reported that specialized hospitals have good infrastructure, as well as supporting working environments, which leads to positive outcomes such as job performance, job satisfaction, and quality of care.

The results of the Mann-Whitney U test indicated a statistically significant difference in the scores of structural empowerment and job performance between nurses working on fixed and rotating shifts. Nurses working on fixed shifts were found to have better scores as compared with those working on rotating shifts. Mudallal et al27 found that nurses who work on fixed shifts typically have more experience than those who work on rotating shifts; therefore, they will contribute more to their job and have a better understanding of their role, which in turn improves their performance and feelings of personal accomplishment.

There was no significant difference in the scores of structural empowerment and job performance according to the specialty area of the study participants. There are no studies that compare the variations of the perceived levels of structural empowerment or job performance based on the type of work units (general units or critical care units). Mrayyan and Al-Faouri21 found no difference in the level of job performance between critical care nurses and general unit nurses.

Conclusion

The findings of the current study have important implications for nurses globally. Applying structural empowerment in the work setting is crucial for ensuring the highest quality of patient care, nursing satisfaction, patient satisfaction, and low burnout and reaching the organizational goals. Nurse leaders can provide educational sessions and training programs for nurses regarding empowerment and how to practice it in the work environment. Programs need to focus on assessing nurses' knowledge and competence regarding structural empowerment and available resources and information. Administrators should provide support and opportunity for nurses to learn and grow and offer an efficient recognition system for nurses to motivate them and to positively affect their job performance.

There are limitations to our study. Measuring the job performance level as reported by staff members and not their managers may have resulted in reporting bias or subjectivity. Also, the present study is conducted in hospitals in one country, which may affect the generalizability of the study. This study included nurses with BSN or higher education; larger comparative research studies may be helpful in exploring structural empowerment and job performance from the perspectives of LPNs as well as RNs educated in non-BSN programs.

The current study concluded that highly empowered staff members perform better than the less empowered ones. Therefore, structural empowerment had a direct impact on job performance. Empowerment measures should be taken within hospitals to support clinical nurses, which will impact patient care. Nurse managers must create empowering work environments. Further research is needed to study the barriers that administrators face in applying the concept of structural empowerment in the work environment for nurses.

Acknowledgment

The authors are thankful to Jordan University of Science and Technology and Deanship of Scientific Research, College of Nursing Research Center at King Saud University, for funding this research.

References

1. Al-Dmour R, Yassine O, Masa' deh R. A review of literature on the associations among employee empowerment, work engagement and employee performance. Mod Appl Sci. 2018;12(11).
2. Chung CE, Kowalski S. Job stress, mentoring, psychological empowerment, and job satisfaction among nursing faculty. J Nurs Educ. 2012;51(7):381–388.
3. Manojlovich M. Power and empowerment in nursing: looking backward to inform the future. Online J Issues Nurs. 2007;12(1):2.
4. Seibert SE, Wang G, Courtright SH. Antecedents and consequences of psychological and team empowerment in organizations: a meta-analytic review. J Appl Psychol. 2011;96(5):981–1003.
5. Yang J, Liu Y, Chen YF, Pan X. The effect of structural empowerment and organizational commitment on Chinese nurses' job satisfaction. Appl Nurs Res. 2014;27(3):186–191.
6. World Health Organization, Organization for Economic Co-operation and Development, and The World Bank. Delivering quality health services: a global imperative for universal health coverage. https://www.worldbank.org/en/topic/universalhealthcoverage/publication/delivering-quality-health-services-a-global-imperative-for-universal-health-coverage. Published July 5, 2018. Accessed July 25, 2020.
7. World Health Organization. The World Health Report 2010—health systems financing: the path to universal coverage. https://www.who.int/whr/2010/en/. Accessed July 25, 2020.
8. Cicolini G, Comparcini D, Simonetti V. Workplace empowerment and nurses' job satisfaction: a systematic literature review. J Nurs Manag. 2014;22(7):855–871.
9. Kanter R. Men and women of the corporation revisited. Manage Rev. 1987;76(3):14.
10. American Nurses Credentialing Center (ANCC). Magnet model—creating a Magnet culture. https://www.nursingworld.org/organizational-programs/magnet/magnet-model/. Accessed July 27, 2020.
11. Valdez GFD, Cayaban AR, Mathews S, Doloolat ZA. Workplace empowerment, burnout, and job satisfaction among nursing faculty members: testing Kanter's theory. Int J Palliat Nurs. 2019;2(1):29–35. doi:10.30881/npcij.00012.
12. Sarmiento TP, Laschinger HK, Iwasiw C. Nurse educators' workplace empowerment, burnout, and job satisfaction: testing Kanter's theory. J Adv Nurs. 2004;46(2):134–143.
13. McConnell CR. Managing employee performance. Health Care Manag (Frederick). 2004;23(3):273–283.
14. Awases MH. Factors Affecting Performance of Professional Nurses in Namibia [PhD thesis]. Namibia, South Africa: University of South Africa; 2006.
15. Al-Dweik G, Al-Daken L, Abu-Snieneh H, Ahmad M. Work-related empowerment among nurses: literature review. Int J Product Qual Manag. 2016;19(2):168–186.
16. Benbow S, Ta'an W, Terp M, Haspeslagh M, Forchuk C. Mental health care nursing standards: international perspectives. In: Yearwood EL, Hines VP, eds. Routledge Handbook of Global Mental Health Nursing. Routledge; 2017:103–121.
17. Cohen J. A power primer. Psychol Bull. 1992;112(1):155–159.
18. Laschinger HK, Finegan J, Shamian J, Wilk P. Impact of structural and psychological empowerment on job strain in nursing work settings: expanding Kanter's model. J Nurs Adm. 2001;31(5):260–272.
19. Laschinger HKS. Conditions for Work Effectiveness Questionnaire I and II: user manual. 2012. https://www.uwo.ca/fhs/hkl/cweq.html. Accessed July 26, 2020.
20. Schwirian P. Evaluating the performance of nurses: a multidimensional approach. Nurs Res. 1978;27(6):347–351.
21. Mrayyan MT, Al-Faouri I. Career commitment and job performance of Jordanian nurses. Nurs Forum. 2008;43(1):24–37.
22. Istomina N, Suominen T, Razbadauskas A, Martinkenas A, Kuokkanen L, Leino-Kilpi H. Lithuanian nurses' assessments of their empowerment. Scand J Caring Sci. 2012;26(1):3–11.
23. Safarpour H, Sabzevari S, Delpisheh A. A study on the occupational stress, job satisfaction and job performance among hospital nurses in Ilam. Iran J Clin Diagn Res. 2018;12(6):1–5.
24. Nagaraju B, Pooja J. Impact of salary on employee performance empirical evidence from public and private sector banks of Karnataka. IJMHRM. 2017;8(4):43–51.
25. Tyagi P, Shah H. Impact of structural empowerment on organisational performance: ‘empowerment-HR’ interface. Int J Intell Enterp. 2018;5(4):365–384.
26. Keuter K, Byrne E, Voell J, Larson E. Nurses' job satisfaction and organizational climate in a dynamic work environment. Appl Nurs Res. 2000;13(1):46–49.
27. Mudallal RH, Othman WM, Al Hassan NF. Nurses' burnout: the influence of leader empowering behaviors, work conditions, and demographic traits. Inquiry. 2017;54:46958017724944.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.