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The relationship between nurses' perceptions of empowerment and patient satisfaction
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Applied Nursing Research 21 (2008) 2 – 7 www.elsevier.com/locate/apnr
Original Articles
The relationship between nurses' perceptions of empowerment and patient satisfaction Moreen O. Donahue, DNP, RN, CNA, BC a,⁎, Irene M. Piazza, DNP, RN, AOCNS b , Mary Quinn Griffin, PhD, RN c , Patricia C. Dykes, DNSc, RN d , Joyce J. Fitzpatrick, PhD, RN, FAAN e a
Danbury Hospital, Danbury, CT 06810 Greenwich Hospital, Greenwich CT 06830 c Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio d Partners HealthCare, Wellesley, MA e Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio b
Abstract
Purpose: This study aims to explore the relationship between nurses' perceptions of empowerment and patient satisfaction using Kanter's theory as adapted by Laschinger and others. Research Question: Is there a positive relationship between nurses' perceptions of empowerment and patient satisfaction? Method: A descriptive correlational design was used. Instruments used were the Conditions of Work Effectiveness Questionnaire II, which measures nurse empowerment, and the Press Ganey Associates Patient Satisfaction Surveys, which measures patient satisfaction. Results/Conclusions: Significant relationships were found between nurses' perceptions of empowerment and access to information, opportunity, support, and resources. A significant positive correlation was found between nurses' perceptions of empowerment and patient satisfaction (r = .052; p b .05). Limitations of this study are presented, as well as recommendations for future research. © 2008 Elsevier Inc. All rights reserved.
Nurse executives play a critical role in the establishment and maintenance of environments that promote professional practice. A culture that supports autonomy, control over the practice environment, and collaborative physician relationships is characteristic of hospitals that have been successful in attracting and retaining nurses. Nurse recruitment and retention strategies are essential components of hospital business plans that also include expanding market share and increasing patient volume. The purpose of this nurse empowerment and patient satisfaction study was to examine the relationship between nurses' perceptions of empowerment and patient satisfaction at a single community hospital located in the Northeastern United States. Results of this
⁎ Corresponding author. Tel.: +1 203 268 8662. E-mail address: [email protected] (M.O. Donahue). 0897-1897/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.apnr.2007.11.001
study suggest the relationship between nurse empowerment and patient satisfaction.
1. Background and significance Nurses' job satisfaction and patient satisfaction are important issues in today's competitive health care market. Kanter's (1993) theory of structural empowerment, although first applied in the business field, has been validated in the health care clinical arena by a number of nurse researchers. Chandler (1986) was the first researcher to examine Kanter's theory in relation to nurses' perceptions of power using the Conditions of Work Effectiveness Questionnaire (CWEQ) tool. Kanter's theoretical structure was confirmed by this work and has subsequently become the basis for other nursing studies (Laschinger & Finegan, 2005; Piazza, Donahue, Dykes, Quinn Griffin, & Fitzpatrick, 2006).
M.O. Donahue et al. / Applied Nursing Research 21 (2008) 2–7
These investigations showed the relative ease of adapting Kanter's theory to various care settings, nursing populations, and management styles. Results of studies indicate positive outcomes for empowered participants including higher levels of job autonomy, increased job satisfaction (Laschinger & Finegan, 2005), higher levels of organizational commitment, and greater trust in the organization (Laschinger & Finegan, 2005; Laschinger, Finegan, Shamian, & Casier, 2000). Because no previously published studies linking nurse empowerment to patient satisfaction were found, this study was designed to explore that relationship. A review of the literature relevant to the concepts of nurse empowerment and patient satisfaction suggested evidence that creating work environments that promote nurse empowerment can influence positive patient outcomes (Laschinger & Finegan, 2005). Nurses who perceive themselves to be empowered are more likely to use more effective work practices. As a result, positive patient outcomes can occur. Many of the studies examining nurse empowerment were undertaken by the faculty of the University of Western Ontario, London, Ontario, Canada and were primarily based on Kanter's theory of structural power in organizations (Laschinger, 2005; Laschinger & Finegan, 2005; Laschinger et al., 2000). Earlier studies examined organization theory, critical social theory, and social psychological theory (Kuokkanen & Leino-Kilpi, 2000). Many factors have been linked with patient satisfaction, including satisfaction with nursing care (Aiello, Garman, & Morris, 2003; Al-Mailam, 2005; Kangus, Kee, & McKeeWaddle, 1999). Recurrent themes included technical and interpersonal competence and the ability to convey health care information. Measures associated with overall patient satisfaction included the likelihood to return to the same facility for care and the likelihood to recommend this facility to others needing care (Al-Mailam, 2005; Trout, Magnusson, & Hedges, 2000).
2. Conceptual framework Laschinger's conceptual model based on Kanter's theory of structural power in organizations provided the conceptual framework for this study (Laschinger, Finegan, Shamian, & Wilk, 2001). A relationship between nurses' perceptions of empowerment and client (patient) satisfaction is suggested in the model. Concepts of Kanter's theory of structural power are composed of four components that are arranged in a linear relationship: systemic power factors influence or determine access to job-related empowerment structures that lead to personal impact on employees, which results in work effectiveness. Job-related empowerment structures include access to information, support, resources, and opportunities for growth and promotion. These empowerment structures further strengthen the individual's position and sense of efficacy to get things done in the organization.
3
Work effectiveness is the goal of an organizational model that promotes a participative management style. Achievement and success, respect and cooperation in the organization, and satisfaction are essentially outcomes or benefits of empowerment. 3. Methods A descriptive correlational design and a cross-sectional approach were used for this study. The variables examined were nurse empowerment and patient satisfaction. Predictor variables for nurse empowerment included age of the nurse, degree held, years in nursing, years working at the study hospital, specialty area, position within the organization, and certification status. 3.1. Nurse empowerment Nurse empowerment was measured using the Conditions of Work Effectiveness Questionnaire II (CWEQ-II). The CWEQ-II is a shortened version of the CWEQ, which was adapted by Chandler in 1986 for use in nursing populations. The CWEQ-II consists of 19 items that measure the six components of empowerment described by Kanter: opportunity, information, support, resources, formal power and informal power, and a 2-item global empowerment scale. Construct validity of the CWEQ-II was substantiated in a confirmatory factor analysis that revealed a good fit of the hypothesized factor structure (RMSEA = .054). The CWEQII also correlated highly with the global measure of empowerment (r = 0.56; Laschinger et al., 2001). 3.2. Patient satisfaction The instruments used to measure patient satisfaction were developed in 1987 by Press Ganey Associates and were revised between 1999 and 2002. Information related to the psychometric qualities of the Press Ganey Survey forms was obtained from the Research and Development Offices of Press Ganey Associates located in South Bend, IN. Test items for the patient satisfaction scales were developed through the use of focus groups, structured conference calls with health care facilities in the United States, patients, direct care providers, and hospital administrators who were using the data for quality improvement initiatives. Cronbach's alpha values for each of the subscales ranged from .84 to .95. The reliability value for the overall questionnaire was reported to be .98. Construct validity of the surveys was evaluated through factor analysis, and results confirmed convergent and discriminate validity of the instrument (Press Ganey Associates, 2002). A convenience sample of 259 nurses representing a 58% return rate was obtained from all active-status, registered nurses employed at the study hospital. Patient satisfaction data are routinely obtained by the study hospital on a quarterly basis. The sample for this study included the most recent patient satisfaction survey scores available from Press
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M.O. Donahue et al. / Applied Nursing Research 21 (2008) 2–7
Ganey Associates, South Bend, IN, at the time of the study. As suggested by Press Ganey's Research and Development Department, the overall satisfaction, overall nursing, and likelihood to recommend scores were included in the study. The size of this sample included 622 survey responses for inpatients, 679 responses for ambulatory surgery, and 305 responses for the emergency department. Prestudy power analysis indicated a need for 114 participants for a power of .8 and an alpha of .05.
4. Protection of human subjects This research study involved no more than minimal risk to the subjects (nurse subjects and patients) and involved no procedures for which written consent is normally required outside the research context. Institutional review board approvals were obtained. Nurses' and patients' consent for participation in this study were indicated by the return of the questionnaire or survey.
5. Results Data of participating nurses for this study was collected at one point in time. Nurses' questionnaires were attached to the paychecks of all active-status, registered nurses and were returned to confidential containers located throughout the hospital. Reminder letters were sent to all nurses in an attempt to improve the return rate. Questionnaires with more than 10% missing data were excluded. Patient satisfaction data were collected by Press Ganey Associates, South Bend, IN, according to procedures already in place at the study hospital. Press Ganey data files containing the most recent quarterly data were obtained from the company during the data collection period. To control for possible lag time between actual care delivery and survey return, only those nurses who were employed at least 6 months before the Press Ganey data collection period were included in the study. Pearson's product–moment correlation was used to examine the strength of the relationship between nurse empowerment and patient satisfaction, and multiple-regression analysis was used to explore the predictive ability of nurse-related factors on empowerment. Demographic data for the nursing sample were obtained using descriptive statistics. Most of the respondents reported working in staff nurse positions (72.2%), and 66% indicated that they were educated at the baccalaureate level or higher. Master's degrees were held by 15.8% of the nurses. Additional results are displayed in Table 1. Demographic data for patient satisfaction were obtained by the Press Ganey Associates. A total of 679 ambulatory surgery patient surveys, 305 emergency department patient surveys, and 622 inpatient surveys were obtained. Data supplied by Press Ganey Associates revealed that 62% of the
Table 1 Demographic data for the nursing sample Data Gender Female Male Age 23–30 31–40 41–50 51–60 61–77 Race Caucasian Asian African American Other Chose not to respond Years in nursing 0.3–10 11–20 21–30 31–55 Years at Greenwich Hospital ≤5 6–10 11–20 21–30 31–40 41–50 Certification status No Yes Currently enrolled in school No Yes
n
%
252 7 259 35 57 97 57 13
97.3 2.7
216 11 8 9 8
85.7 4.4 3.2 3.6 3.2
73 64 72 50
28.2 24.7 27.8 19.3
115 41 55 33 13 2
44.4 15.8 21.2 12.7 5.0 .8
155 103
60.1 39.9
211 48
81.5 18.5
M
SD
Range
44.05
10.31
23–77
19.71
11.79
.3–55
10.917
10.2802
.3 to 45
13.5 22 37.5 22 5
ambulatory surgery respondents were female and 59% were between the ages of 50 and 79 years. Females represented 59% of the emergency department sample, and 135 patients or 44% indicated that they were 50 years or older. Inpatient demographic data provided by Press Ganey Associates revealed that most of the patients were female and composed 73% of the sample. A total of 341 patients or 54% were 49 years or younger. Those who were 65 years or older represented 30% of the total. Patients who rated their health as good (n = 208) or very good (n = 297) represented 83% of the sample. Laschinger (2005) describes empowerment in terms of low, moderate, and high ranges. Descriptive statistics revealed a total nurse empowerment score of 21.28 for the study hospital registered nurses, which indicated a moderate level of empowerment. CWEQ-II scores ranging from 23 to 30 are viewed by Laschinger as indicative of high levels of empowerment. Nurses in management positions in the hospital scored within this range with a total score of 24.39. Scores between 14 and 22 indicate a moderate level of empowerment. The study hospital staff nurses scored 20.40. Advanced practice nurses also indicated moderate empowerment with a total score of 21.97.
M.O. Donahue et al. / Applied Nursing Research 21 (2008) 2–7
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Table 2 Pearson correlation: staff nurse empowerment and patient satisfaction Outcome measure
Statistical test
CWEQ-II mean
CWEQ-II
Pearson correlation Significance (one-tailed) Pearson correlation Significance (one-tailed) Pearson correlation Significance (one-tailed) Pearson correlation Significance (one-tailed)
1
Press Ganey nursing overall Press Ganey likelihood to recommend Press Ganey overall satisfaction
.104 .077 .048 .257 .169 ⁎ .011
Press Ganey nursing overall
Press Ganey l ikelihood recommend
Press Ganey overall satisfaction
1 .935 ⁎⁎ .000 .806 ⁎⁎ .000
1 .775 ⁎⁎ .000
1
n = 187 staff nurse responses; n = 1,588 patient responses. ⁎ Correlation is significant at the .05 level (one-tailed). ⁎⁎ Correlation is significant at the .01 level (one-tailed).
Cronbach's coefficient alpha was used to test the CWEQII scales using SPSS. The total CWEQ-II alpha in this study was .778. Cronbach's alpha values of the subscales ranged from .803 to .851. Construct validity results were acceptable (r = .846). Correlation analysis was used to describe the strength of the relationship between nurses' perceptions of empowerment and patient satisfaction. Pearson's product–moment correlation coefficients were computed. Results indicated that there was a significant positive correlation between the CWEQ-II total nurse empowerment scores and the Press Ganey Overall Satisfaction Scores (r = .052; p b .05). Because staff nurses comprised 72.2% of the nursing sample, Pearson's product–moment correlation coefficients were computed to explore the relationship between staff nurses' perceptions of empowerment and patient satisfaction. Staff nurse CWEQ-II total empowerment scores and Press Ganey Overall Satisfaction scores also indicated a significant positive correlation (r = .169; p b .05). Staff nurse correlations are displayed in Table 2.
6. Additional analysis Multiple regression analysis was used to test factors believed to influence nurses' perceptions of empowerment. The factors analyzed were age of the nurse, degree held, years in nursing, years at the study hospital, specialty area, position within the organization, and certification status. The relative contribution of each of these independent variables was examined to determine their unique contribution to variability in empowerment scores. Results showed that position in the organization was a significant predictor of nurse empowerment (p = .023). Nurses in management positions scored in the highly empowered range with a total score of 24.39. As described above, removing the management scores from the sample did not alter the statistical significance. The difference between staff nurses' perceptions of empowerment and that of all other nurses was not significant.
7. Discussion Although position in the organization was a significant predictor of nurse empowerment, 92.2% of the variance in empowerment remained unexplained. The inclusion of such factors as membership in professional organizations and hospital committee appointments might have provided more information. Nurses with a master's degree or higher at the study hospital perceived themselves to be highly empowered with total scores of 23.98 to 28.83. Diploma nurses had higher perceptions of total empowerment (M = 22.25) than nurses with a bachelor's degree in nursing (M = 20.64). This difference in scores may be explained by the difference in years of experience between the two groups. Nurses with diploma degrees had a mean of 26 years of experience in nursing compared to a mean of 17 years of experience for nurses prepared at the bachelor of science level. This view is supported by the work of Koberg, Boss, Senjem, and Goodman (1999), who found that perceptions of empowerment increased with rank and tenure in the organization. They believed that more tenured employees have learned through experience to adapt to the work situations. The total nurse empowerment mean score was 3.55, with 5 indicating high empowerment. Upenieks (2003) obtained the same result for magnet hospital nurses in her study, which examined differences in workplace empowerment. Table 3 Comparison of staff nurse empowerment scores: this study with findings of previous studies (1992–2004) a using CWEQ-II instrument CWEQ-II
Total Empowerment Formal Power Informal Power
Current study
Previous studies a
Mean
Mean
20.04 3.19 3.53
17.29–19.60 2.44–2.92 3.35–3.73
Note. Scale range = 1–5: 1 = low, 5 = high. Total CWEQ-II empowerment scores range from 6–30, with 14–22 indicating moderate empowerment and 23–30 indicating high empowerment. a Laschinger (2005).
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M.O. Donahue et al. / Applied Nursing Research 21 (2008) 2–7
Table 4 Comparison of staff nurse empowerment structural component scores: this study with findings of previous studies ⁎ using CWEQ-II instrument a Laschinger et al. (2001) urban hospitals (n = 404)
a Upenieks (2001) magnet hospitals (n = 144)
a Upenieks (2001) nonmagnet hospitals (n = 161)
M
M
M
M
3.8 3.26 3.2 3.42
3.85 3.46 2.94 2.64
4.04 3.00 3.40 3.02
3.88 2.83 2.85 2.37
CWEQ-II Donahue structural (2005) components community hospital (n = 187)
Opportunity Information Support Resources
Note. Scale range = 1–5: 1 = low, 5 = high. a Laschinger (2005).
Most of the study hospital staff nurse empowerment scores are higher than the compilation of studies reported by Laschinger (2005) on her Web site. Comparative data are presented in Table 3. A possible explanation for the relatively high study hospital scores may be the physical design of the hospital, which was constructed in 1999 to support and enhance the effectiveness of patient care. Staff nurses were included in the planning of the hospital layout, and a patient-focused model was used. Patient information centers were strategically placed throughout the hospital, and nurses were given access to computerized patient records, policies and procedures, medication information, patient education tools, and reference materials. Supply areas were also strategically placed so that patient care items would be readily available. Comparison of the study hospital staff nurse structural component scores with findings of previous studies as reported by Laschinger (2005) are displayed in Table 4. Nurses rated access to opportunity as the highest subscale. One reason may be the availability of educational opportunities. The study hospital partners with universities and community colleges to provide baccalaureate, master, and doctoral level courses on site. This support for the professional development and education of the nurses may have increased their sense of empowerment. This is consistent with the findings of magnet hospital research (Upenieks, 2003). A significant positive relationship between nurses' perceptions of empowerment and patient satisfaction scores was found in this study. Pearson's product–moment correlation obtained through the use of the SPSS statistical package indicated a Pearson correlation coefficient (r) value of .052 (p b .05). Staff nurse results were similar (r = .169; p.05). Correlations, although significant, were small. Several possibilities are suggested by these results. The overall nurse empowerment score approached the highly empowered level. Patient satisfaction scores indicated that the respondents were very satisfied. Insufficient variability in these scores may have prevented the detection of a stronger positive relationship. This study was cross-sectional in design, and a single self-assessment was used to capture
the continuous variables. Longitudinal studies may be better determinants of these relationships. 8. Limitations This study examining nurses' perceptions of empowerment and patient satisfaction had limitations associated with the sampling methodology, the study methodology, data collection, and analysis. The study was conducted in a single, affluent community hospital located in the Northeastern United States. The study included only nurses who chose to answer the CWEQ-II, so the results may not be indicative of the entire population. Although the return rate of 58% was adequate, completion of the questionnaire was voluntary and nurses with higher perceptions of personal empowerment may have elected to respond to the questionnaire. Similarly, response to the Press Ganey survey is voluntary and may not represent the entire population of patients cared for at the study hospital at the time of data collection. There is no way to assure that responses were completed by the patients and not their family members or others. Further limitations of this study may be related to the demographic and socioeconomic profile of the study hospital community. Older patients and those with better perceived health status may rate hospital care more positively. In addition, people in higher income brackets may assess their care more positively. Finally, the generalizability of results is affected by the demographics of the nursing and patient populations and is limited to the research setting. 9. Implications for nursing and future research Strategies that may promote nurse empowerment may include improving methods of communication throughout the organization. Direct communication by the nurse executive with new nurse employees during the orientation process can increase knowledge about the vision and mission of the organization. Information about opportunities, support, and resources available to them to enhance their productivity, effectiveness, and job satisfaction can also be communicated at this time. Creating more opportunities for nurses at all levels of the organization to serve on hospital and system committees may build relationships within and outside the organization. Future research should be conducted to develop and test models that measure the effects of these strategies on patient satisfaction and other patient outcomes. The purpose of this Nurse Empowerment and Patient Satisfaction study was to evaluate the relationship between nurses' perceptions of empowerment and patient satisfaction at the study hospital. Results of this study suggest a relationship between nurse empowerment and patient satisfaction. Significant relationships were found between nurses' perceptions of empowerment and access to information, opportunity, support, and resources. Similarly, patients who
M.O. Donahue et al. / Applied Nursing Research 21 (2008) 2–7
were very satisfied with the skill of the nurses were also very satisfied with their overall care and very likely to recommend the services of the hospital. Additional research exploring the reasons why patients choose to return to the hospital should be considered. The satisfaction of the family members and/or caregivers as compared with the patient may also provide useful information in terms of marketing strategies to promote increased and repeat hospital business. This study provides information about environments that support nurses' perceptions of empowerment and patient satisfaction with care. The present competitive health care environment underscores the importance of understanding environments that support nursing practice, improve patient satisfaction with care, and ultimately promote positive patient outcomes. References Aiello, A., Garman, A., & Morris, S. B. (2003). Patient satisfaction with nursing care: A multilevel analysis. Quality Management in Health Care 12(3), 187−190. Al-Mailam, F. (2005). The effect of nursing care on overall patient satisfaction and its predictive value on return-to-provider behavior: A survey study. Quality Management in Health Care 14(2), 116−120. Chandler G. (1986). The relationship of nursing work environments to empowerment and powerlessness. Unpublished doctoral dissertation, University of Utah. Kangus, S., Kee, C. C., & McKee-Waddle, R. (1999). Organizational factors, nurses' job satisfaction, and patient satisfaction with nursing care. The Journal of Nursing Administration 29(1), 32−42.
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Kanter, R. M. (1993). Men and women of the corporation. New York, NY: Basic Books. Koberg, C. S., Boss, R. W., Senjem, J. C., & Goodman, E. A. (1999). Antecedents and outcomes of empowerment. Group and Organization Management 24(1), 71−91. Kuokkanen, L., & Leino-Kilpi, H. (2000). Power and empowerment in nursing: Three approaches. Journal of Advanced Nursing 31(1), 235−241. Laschinger, H., Finegan, J., Shamian, J., & Wilk, P. (2001). Impact of structural and psychological empowerment on job strain in nursing work settings: Expanding Kanter's model. Journal of Nursing Administration 31(5), 260−272. Laschinger, H. K., Finegan, J., Shamian, J., & Casier, S. (2000). Organizational trust and empowerment in restructured healthcare settings: Effects on staff nurse commitment. Journal of Nursing Administration 30(9), 413−425. Laschinger, H. K., & Finegan, J. (2005). Using empowerment to build trust and respect in the workplace: A strategy for addressing the nursing shortage. Nursing Economic$ 23(1), 6−13. Laschinger, H. K. S. (2005). UWO workplace empowerment research program 1992–2004 descriptive statistics results. Retrieved March 19, 2007, from http://publish.uwo.ca/∼hkl/descrip.html. Piazza, I., Donahue, M., Dykes, P., Quinn Griffin, M., & Fitzpatrick, J. (2006). Differences in perceptions of empowerment among nationally certified and non-certified nurses. The Journal of Nursing Administration 36(5), 277−283. Press Ganey Associates (2002). Inpatient psychometrics. South Bend, IN: Press Ganey Associates, Inc. Trout, A., Magnusson, A. R., & Hedges, J. R. (2000). Patient satisfaction investigations and the emergency department: What does the literature say? Academic Emergency Medicine 7(6), 695−709. Upenieks, V. (2003). The interrelationship between organizational characteristics of magnet hospitals, nursing leadership, and nursing job satisfaction. Health Care Manager 22(2), 83−98.
Applied Nursing Research 21 (2008) 2 – 7 www.elsevier.com/locate/apnr
Original Articles
The relationship between nurses' perceptions of empowerment and patient satisfaction Moreen O. Donahue, DNP, RN, CNA, BC a,⁎, Irene M. Piazza, DNP, RN, AOCNS b , Mary Quinn Griffin, PhD, RN c , Patricia C. Dykes, DNSc, RN d , Joyce J. Fitzpatrick, PhD, RN, FAAN e a
Danbury Hospital, Danbury, CT 06810 Greenwich Hospital, Greenwich CT 06830 c Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio d Partners HealthCare, Wellesley, MA e Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio b
Abstract
Purpose: This study aims to explore the relationship between nurses' perceptions of empowerment and patient satisfaction using Kanter's theory as adapted by Laschinger and others. Research Question: Is there a positive relationship between nurses' perceptions of empowerment and patient satisfaction? Method: A descriptive correlational design was used. Instruments used were the Conditions of Work Effectiveness Questionnaire II, which measures nurse empowerment, and the Press Ganey Associates Patient Satisfaction Surveys, which measures patient satisfaction. Results/Conclusions: Significant relationships were found between nurses' perceptions of empowerment and access to information, opportunity, support, and resources. A significant positive correlation was found between nurses' perceptions of empowerment and patient satisfaction (r = .052; p b .05). Limitations of this study are presented, as well as recommendations for future research. © 2008 Elsevier Inc. All rights reserved.
Nurse executives play a critical role in the establishment and maintenance of environments that promote professional practice. A culture that supports autonomy, control over the practice environment, and collaborative physician relationships is characteristic of hospitals that have been successful in attracting and retaining nurses. Nurse recruitment and retention strategies are essential components of hospital business plans that also include expanding market share and increasing patient volume. The purpose of this nurse empowerment and patient satisfaction study was to examine the relationship between nurses' perceptions of empowerment and patient satisfaction at a single community hospital located in the Northeastern United States. Results of this
⁎ Corresponding author. Tel.: +1 203 268 8662. E-mail address: [email protected] (M.O. Donahue). 0897-1897/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.apnr.2007.11.001
study suggest the relationship between nurse empowerment and patient satisfaction.
1. Background and significance Nurses' job satisfaction and patient satisfaction are important issues in today's competitive health care market. Kanter's (1993) theory of structural empowerment, although first applied in the business field, has been validated in the health care clinical arena by a number of nurse researchers. Chandler (1986) was the first researcher to examine Kanter's theory in relation to nurses' perceptions of power using the Conditions of Work Effectiveness Questionnaire (CWEQ) tool. Kanter's theoretical structure was confirmed by this work and has subsequently become the basis for other nursing studies (Laschinger & Finegan, 2005; Piazza, Donahue, Dykes, Quinn Griffin, & Fitzpatrick, 2006).
M.O. Donahue et al. / Applied Nursing Research 21 (2008) 2–7
These investigations showed the relative ease of adapting Kanter's theory to various care settings, nursing populations, and management styles. Results of studies indicate positive outcomes for empowered participants including higher levels of job autonomy, increased job satisfaction (Laschinger & Finegan, 2005), higher levels of organizational commitment, and greater trust in the organization (Laschinger & Finegan, 2005; Laschinger, Finegan, Shamian, & Casier, 2000). Because no previously published studies linking nurse empowerment to patient satisfaction were found, this study was designed to explore that relationship. A review of the literature relevant to the concepts of nurse empowerment and patient satisfaction suggested evidence that creating work environments that promote nurse empowerment can influence positive patient outcomes (Laschinger & Finegan, 2005). Nurses who perceive themselves to be empowered are more likely to use more effective work practices. As a result, positive patient outcomes can occur. Many of the studies examining nurse empowerment were undertaken by the faculty of the University of Western Ontario, London, Ontario, Canada and were primarily based on Kanter's theory of structural power in organizations (Laschinger, 2005; Laschinger & Finegan, 2005; Laschinger et al., 2000). Earlier studies examined organization theory, critical social theory, and social psychological theory (Kuokkanen & Leino-Kilpi, 2000). Many factors have been linked with patient satisfaction, including satisfaction with nursing care (Aiello, Garman, & Morris, 2003; Al-Mailam, 2005; Kangus, Kee, & McKeeWaddle, 1999). Recurrent themes included technical and interpersonal competence and the ability to convey health care information. Measures associated with overall patient satisfaction included the likelihood to return to the same facility for care and the likelihood to recommend this facility to others needing care (Al-Mailam, 2005; Trout, Magnusson, & Hedges, 2000).
2. Conceptual framework Laschinger's conceptual model based on Kanter's theory of structural power in organizations provided the conceptual framework for this study (Laschinger, Finegan, Shamian, & Wilk, 2001). A relationship between nurses' perceptions of empowerment and client (patient) satisfaction is suggested in the model. Concepts of Kanter's theory of structural power are composed of four components that are arranged in a linear relationship: systemic power factors influence or determine access to job-related empowerment structures that lead to personal impact on employees, which results in work effectiveness. Job-related empowerment structures include access to information, support, resources, and opportunities for growth and promotion. These empowerment structures further strengthen the individual's position and sense of efficacy to get things done in the organization.
3
Work effectiveness is the goal of an organizational model that promotes a participative management style. Achievement and success, respect and cooperation in the organization, and satisfaction are essentially outcomes or benefits of empowerment. 3. Methods A descriptive correlational design and a cross-sectional approach were used for this study. The variables examined were nurse empowerment and patient satisfaction. Predictor variables for nurse empowerment included age of the nurse, degree held, years in nursing, years working at the study hospital, specialty area, position within the organization, and certification status. 3.1. Nurse empowerment Nurse empowerment was measured using the Conditions of Work Effectiveness Questionnaire II (CWEQ-II). The CWEQ-II is a shortened version of the CWEQ, which was adapted by Chandler in 1986 for use in nursing populations. The CWEQ-II consists of 19 items that measure the six components of empowerment described by Kanter: opportunity, information, support, resources, formal power and informal power, and a 2-item global empowerment scale. Construct validity of the CWEQ-II was substantiated in a confirmatory factor analysis that revealed a good fit of the hypothesized factor structure (RMSEA = .054). The CWEQII also correlated highly with the global measure of empowerment (r = 0.56; Laschinger et al., 2001). 3.2. Patient satisfaction The instruments used to measure patient satisfaction were developed in 1987 by Press Ganey Associates and were revised between 1999 and 2002. Information related to the psychometric qualities of the Press Ganey Survey forms was obtained from the Research and Development Offices of Press Ganey Associates located in South Bend, IN. Test items for the patient satisfaction scales were developed through the use of focus groups, structured conference calls with health care facilities in the United States, patients, direct care providers, and hospital administrators who were using the data for quality improvement initiatives. Cronbach's alpha values for each of the subscales ranged from .84 to .95. The reliability value for the overall questionnaire was reported to be .98. Construct validity of the surveys was evaluated through factor analysis, and results confirmed convergent and discriminate validity of the instrument (Press Ganey Associates, 2002). A convenience sample of 259 nurses representing a 58% return rate was obtained from all active-status, registered nurses employed at the study hospital. Patient satisfaction data are routinely obtained by the study hospital on a quarterly basis. The sample for this study included the most recent patient satisfaction survey scores available from Press
4
M.O. Donahue et al. / Applied Nursing Research 21 (2008) 2–7
Ganey Associates, South Bend, IN, at the time of the study. As suggested by Press Ganey's Research and Development Department, the overall satisfaction, overall nursing, and likelihood to recommend scores were included in the study. The size of this sample included 622 survey responses for inpatients, 679 responses for ambulatory surgery, and 305 responses for the emergency department. Prestudy power analysis indicated a need for 114 participants for a power of .8 and an alpha of .05.
4. Protection of human subjects This research study involved no more than minimal risk to the subjects (nurse subjects and patients) and involved no procedures for which written consent is normally required outside the research context. Institutional review board approvals were obtained. Nurses' and patients' consent for participation in this study were indicated by the return of the questionnaire or survey.
5. Results Data of participating nurses for this study was collected at one point in time. Nurses' questionnaires were attached to the paychecks of all active-status, registered nurses and were returned to confidential containers located throughout the hospital. Reminder letters were sent to all nurses in an attempt to improve the return rate. Questionnaires with more than 10% missing data were excluded. Patient satisfaction data were collected by Press Ganey Associates, South Bend, IN, according to procedures already in place at the study hospital. Press Ganey data files containing the most recent quarterly data were obtained from the company during the data collection period. To control for possible lag time between actual care delivery and survey return, only those nurses who were employed at least 6 months before the Press Ganey data collection period were included in the study. Pearson's product–moment correlation was used to examine the strength of the relationship between nurse empowerment and patient satisfaction, and multiple-regression analysis was used to explore the predictive ability of nurse-related factors on empowerment. Demographic data for the nursing sample were obtained using descriptive statistics. Most of the respondents reported working in staff nurse positions (72.2%), and 66% indicated that they were educated at the baccalaureate level or higher. Master's degrees were held by 15.8% of the nurses. Additional results are displayed in Table 1. Demographic data for patient satisfaction were obtained by the Press Ganey Associates. A total of 679 ambulatory surgery patient surveys, 305 emergency department patient surveys, and 622 inpatient surveys were obtained. Data supplied by Press Ganey Associates revealed that 62% of the
Table 1 Demographic data for the nursing sample Data Gender Female Male Age 23–30 31–40 41–50 51–60 61–77 Race Caucasian Asian African American Other Chose not to respond Years in nursing 0.3–10 11–20 21–30 31–55 Years at Greenwich Hospital ≤5 6–10 11–20 21–30 31–40 41–50 Certification status No Yes Currently enrolled in school No Yes
n
%
252 7 259 35 57 97 57 13
97.3 2.7
216 11 8 9 8
85.7 4.4 3.2 3.6 3.2
73 64 72 50
28.2 24.7 27.8 19.3
115 41 55 33 13 2
44.4 15.8 21.2 12.7 5.0 .8
155 103
60.1 39.9
211 48
81.5 18.5
M
SD
Range
44.05
10.31
23–77
19.71
11.79
.3–55
10.917
10.2802
.3 to 45
13.5 22 37.5 22 5
ambulatory surgery respondents were female and 59% were between the ages of 50 and 79 years. Females represented 59% of the emergency department sample, and 135 patients or 44% indicated that they were 50 years or older. Inpatient demographic data provided by Press Ganey Associates revealed that most of the patients were female and composed 73% of the sample. A total of 341 patients or 54% were 49 years or younger. Those who were 65 years or older represented 30% of the total. Patients who rated their health as good (n = 208) or very good (n = 297) represented 83% of the sample. Laschinger (2005) describes empowerment in terms of low, moderate, and high ranges. Descriptive statistics revealed a total nurse empowerment score of 21.28 for the study hospital registered nurses, which indicated a moderate level of empowerment. CWEQ-II scores ranging from 23 to 30 are viewed by Laschinger as indicative of high levels of empowerment. Nurses in management positions in the hospital scored within this range with a total score of 24.39. Scores between 14 and 22 indicate a moderate level of empowerment. The study hospital staff nurses scored 20.40. Advanced practice nurses also indicated moderate empowerment with a total score of 21.97.
M.O. Donahue et al. / Applied Nursing Research 21 (2008) 2–7
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Table 2 Pearson correlation: staff nurse empowerment and patient satisfaction Outcome measure
Statistical test
CWEQ-II mean
CWEQ-II
Pearson correlation Significance (one-tailed) Pearson correlation Significance (one-tailed) Pearson correlation Significance (one-tailed) Pearson correlation Significance (one-tailed)
1
Press Ganey nursing overall Press Ganey likelihood to recommend Press Ganey overall satisfaction
.104 .077 .048 .257 .169 ⁎ .011
Press Ganey nursing overall
Press Ganey l ikelihood recommend
Press Ganey overall satisfaction
1 .935 ⁎⁎ .000 .806 ⁎⁎ .000
1 .775 ⁎⁎ .000
1
n = 187 staff nurse responses; n = 1,588 patient responses. ⁎ Correlation is significant at the .05 level (one-tailed). ⁎⁎ Correlation is significant at the .01 level (one-tailed).
Cronbach's coefficient alpha was used to test the CWEQII scales using SPSS. The total CWEQ-II alpha in this study was .778. Cronbach's alpha values of the subscales ranged from .803 to .851. Construct validity results were acceptable (r = .846). Correlation analysis was used to describe the strength of the relationship between nurses' perceptions of empowerment and patient satisfaction. Pearson's product–moment correlation coefficients were computed. Results indicated that there was a significant positive correlation between the CWEQ-II total nurse empowerment scores and the Press Ganey Overall Satisfaction Scores (r = .052; p b .05). Because staff nurses comprised 72.2% of the nursing sample, Pearson's product–moment correlation coefficients were computed to explore the relationship between staff nurses' perceptions of empowerment and patient satisfaction. Staff nurse CWEQ-II total empowerment scores and Press Ganey Overall Satisfaction scores also indicated a significant positive correlation (r = .169; p b .05). Staff nurse correlations are displayed in Table 2.
6. Additional analysis Multiple regression analysis was used to test factors believed to influence nurses' perceptions of empowerment. The factors analyzed were age of the nurse, degree held, years in nursing, years at the study hospital, specialty area, position within the organization, and certification status. The relative contribution of each of these independent variables was examined to determine their unique contribution to variability in empowerment scores. Results showed that position in the organization was a significant predictor of nurse empowerment (p = .023). Nurses in management positions scored in the highly empowered range with a total score of 24.39. As described above, removing the management scores from the sample did not alter the statistical significance. The difference between staff nurses' perceptions of empowerment and that of all other nurses was not significant.
7. Discussion Although position in the organization was a significant predictor of nurse empowerment, 92.2% of the variance in empowerment remained unexplained. The inclusion of such factors as membership in professional organizations and hospital committee appointments might have provided more information. Nurses with a master's degree or higher at the study hospital perceived themselves to be highly empowered with total scores of 23.98 to 28.83. Diploma nurses had higher perceptions of total empowerment (M = 22.25) than nurses with a bachelor's degree in nursing (M = 20.64). This difference in scores may be explained by the difference in years of experience between the two groups. Nurses with diploma degrees had a mean of 26 years of experience in nursing compared to a mean of 17 years of experience for nurses prepared at the bachelor of science level. This view is supported by the work of Koberg, Boss, Senjem, and Goodman (1999), who found that perceptions of empowerment increased with rank and tenure in the organization. They believed that more tenured employees have learned through experience to adapt to the work situations. The total nurse empowerment mean score was 3.55, with 5 indicating high empowerment. Upenieks (2003) obtained the same result for magnet hospital nurses in her study, which examined differences in workplace empowerment. Table 3 Comparison of staff nurse empowerment scores: this study with findings of previous studies (1992–2004) a using CWEQ-II instrument CWEQ-II
Total Empowerment Formal Power Informal Power
Current study
Previous studies a
Mean
Mean
20.04 3.19 3.53
17.29–19.60 2.44–2.92 3.35–3.73
Note. Scale range = 1–5: 1 = low, 5 = high. Total CWEQ-II empowerment scores range from 6–30, with 14–22 indicating moderate empowerment and 23–30 indicating high empowerment. a Laschinger (2005).
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M.O. Donahue et al. / Applied Nursing Research 21 (2008) 2–7
Table 4 Comparison of staff nurse empowerment structural component scores: this study with findings of previous studies ⁎ using CWEQ-II instrument a Laschinger et al. (2001) urban hospitals (n = 404)
a Upenieks (2001) magnet hospitals (n = 144)
a Upenieks (2001) nonmagnet hospitals (n = 161)
M
M
M
M
3.8 3.26 3.2 3.42
3.85 3.46 2.94 2.64
4.04 3.00 3.40 3.02
3.88 2.83 2.85 2.37
CWEQ-II Donahue structural (2005) components community hospital (n = 187)
Opportunity Information Support Resources
Note. Scale range = 1–5: 1 = low, 5 = high. a Laschinger (2005).
Most of the study hospital staff nurse empowerment scores are higher than the compilation of studies reported by Laschinger (2005) on her Web site. Comparative data are presented in Table 3. A possible explanation for the relatively high study hospital scores may be the physical design of the hospital, which was constructed in 1999 to support and enhance the effectiveness of patient care. Staff nurses were included in the planning of the hospital layout, and a patient-focused model was used. Patient information centers were strategically placed throughout the hospital, and nurses were given access to computerized patient records, policies and procedures, medication information, patient education tools, and reference materials. Supply areas were also strategically placed so that patient care items would be readily available. Comparison of the study hospital staff nurse structural component scores with findings of previous studies as reported by Laschinger (2005) are displayed in Table 4. Nurses rated access to opportunity as the highest subscale. One reason may be the availability of educational opportunities. The study hospital partners with universities and community colleges to provide baccalaureate, master, and doctoral level courses on site. This support for the professional development and education of the nurses may have increased their sense of empowerment. This is consistent with the findings of magnet hospital research (Upenieks, 2003). A significant positive relationship between nurses' perceptions of empowerment and patient satisfaction scores was found in this study. Pearson's product–moment correlation obtained through the use of the SPSS statistical package indicated a Pearson correlation coefficient (r) value of .052 (p b .05). Staff nurse results were similar (r = .169; p.05). Correlations, although significant, were small. Several possibilities are suggested by these results. The overall nurse empowerment score approached the highly empowered level. Patient satisfaction scores indicated that the respondents were very satisfied. Insufficient variability in these scores may have prevented the detection of a stronger positive relationship. This study was cross-sectional in design, and a single self-assessment was used to capture
the continuous variables. Longitudinal studies may be better determinants of these relationships. 8. Limitations This study examining nurses' perceptions of empowerment and patient satisfaction had limitations associated with the sampling methodology, the study methodology, data collection, and analysis. The study was conducted in a single, affluent community hospital located in the Northeastern United States. The study included only nurses who chose to answer the CWEQ-II, so the results may not be indicative of the entire population. Although the return rate of 58% was adequate, completion of the questionnaire was voluntary and nurses with higher perceptions of personal empowerment may have elected to respond to the questionnaire. Similarly, response to the Press Ganey survey is voluntary and may not represent the entire population of patients cared for at the study hospital at the time of data collection. There is no way to assure that responses were completed by the patients and not their family members or others. Further limitations of this study may be related to the demographic and socioeconomic profile of the study hospital community. Older patients and those with better perceived health status may rate hospital care more positively. In addition, people in higher income brackets may assess their care more positively. Finally, the generalizability of results is affected by the demographics of the nursing and patient populations and is limited to the research setting. 9. Implications for nursing and future research Strategies that may promote nurse empowerment may include improving methods of communication throughout the organization. Direct communication by the nurse executive with new nurse employees during the orientation process can increase knowledge about the vision and mission of the organization. Information about opportunities, support, and resources available to them to enhance their productivity, effectiveness, and job satisfaction can also be communicated at this time. Creating more opportunities for nurses at all levels of the organization to serve on hospital and system committees may build relationships within and outside the organization. Future research should be conducted to develop and test models that measure the effects of these strategies on patient satisfaction and other patient outcomes. The purpose of this Nurse Empowerment and Patient Satisfaction study was to evaluate the relationship between nurses' perceptions of empowerment and patient satisfaction at the study hospital. Results of this study suggest a relationship between nurse empowerment and patient satisfaction. Significant relationships were found between nurses' perceptions of empowerment and access to information, opportunity, support, and resources. Similarly, patients who
M.O. Donahue et al. / Applied Nursing Research 21 (2008) 2–7
were very satisfied with the skill of the nurses were also very satisfied with their overall care and very likely to recommend the services of the hospital. Additional research exploring the reasons why patients choose to return to the hospital should be considered. The satisfaction of the family members and/or caregivers as compared with the patient may also provide useful information in terms of marketing strategies to promote increased and repeat hospital business. This study provides information about environments that support nurses' perceptions of empowerment and patient satisfaction with care. The present competitive health care environment underscores the importance of understanding environments that support nursing practice, improve patient satisfaction with care, and ultimately promote positive patient outcomes. References Aiello, A., Garman, A., & Morris, S. B. (2003). Patient satisfaction with nursing care: A multilevel analysis. Quality Management in Health Care 12(3), 187−190. Al-Mailam, F. (2005). The effect of nursing care on overall patient satisfaction and its predictive value on return-to-provider behavior: A survey study. Quality Management in Health Care 14(2), 116−120. Chandler G. (1986). The relationship of nursing work environments to empowerment and powerlessness. Unpublished doctoral dissertation, University of Utah. Kangus, S., Kee, C. C., & McKee-Waddle, R. (1999). Organizational factors, nurses' job satisfaction, and patient satisfaction with nursing care. The Journal of Nursing Administration 29(1), 32−42.
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Kanter, R. M. (1993). Men and women of the corporation. New York, NY: Basic Books. Koberg, C. S., Boss, R. W., Senjem, J. C., & Goodman, E. A. (1999). Antecedents and outcomes of empowerment. Group and Organization Management 24(1), 71−91. Kuokkanen, L., & Leino-Kilpi, H. (2000). Power and empowerment in nursing: Three approaches. Journal of Advanced Nursing 31(1), 235−241. Laschinger, H., Finegan, J., Shamian, J., & Wilk, P. (2001). Impact of structural and psychological empowerment on job strain in nursing work settings: Expanding Kanter's model. Journal of Nursing Administration 31(5), 260−272. Laschinger, H. K., Finegan, J., Shamian, J., & Casier, S. (2000). Organizational trust and empowerment in restructured healthcare settings: Effects on staff nurse commitment. Journal of Nursing Administration 30(9), 413−425. Laschinger, H. K., & Finegan, J. (2005). Using empowerment to build trust and respect in the workplace: A strategy for addressing the nursing shortage. Nursing Economic$ 23(1), 6−13. Laschinger, H. K. S. (2005). UWO workplace empowerment research program 1992–2004 descriptive statistics results. Retrieved March 19, 2007, from http://publish.uwo.ca/∼hkl/descrip.html. Piazza, I., Donahue, M., Dykes, P., Quinn Griffin, M., & Fitzpatrick, J. (2006). Differences in perceptions of empowerment among nationally certified and non-certified nurses. The Journal of Nursing Administration 36(5), 277−283. Press Ganey Associates (2002). Inpatient psychometrics. South Bend, IN: Press Ganey Associates, Inc. Trout, A., Magnusson, A. R., & Hedges, J. R. (2000). Patient satisfaction investigations and the emergency department: What does the literature say? Academic Emergency Medicine 7(6), 695−709. Upenieks, V. (2003). The interrelationship between organizational characteristics of magnet hospitals, nursing leadership, and nursing job satisfaction. Health Care Manager 22(2), 83−98.