Workplace empowerment, job satisfaction and job stress among Italian mental health nurses: an exploratory study

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1 Journal of Nursing Management, 2009, 17, Workplace empowerment, job satisfaction and job stress among Italian mental health nurses: an exploratory study MARINA LAUTIZI RN, MMS 1, HEATHER K. S. LASCHINGER RN, PhD, FCAHS 2 and SANDRA RAVAZZOLO RN, MMS 3 1 Master in Nursing and Midwifery Sciences, Staff Nurse in Department of Mental Health, ASL Roma H, Contract Professor, Bachelor in Nursing, Faculty of Medicine and Surgery, University of ÔTor VergataÕ, Rome, Italy, 2 Distinguished University Professor and Associate Director Nursing Research, Arthur Labatt Family School of Nursing, University of Western Ontario, London, Ontario, Canada and 3 Sciences and Nursing Midwives, Master in Nursing and Midwifery Sciences, Professor in Charge in Nursing Sciences, Nurse Director of Master in Nursing and Midwifery Sciences, Faculty of Medicine and Surgery, University ÔSapienzaÕ of Rome, Latina, Italy. Correspondence Heather K. S. Laschinger Arthur Labatt Family School of Nursing University of Western Ontario London Ontario Canada hkl@uwo.ca LAUTIZI M., LASCHINGER H.K.S. & RAVAZZOLO S. (2009) Journal of Nursing Management 17, Workplace empowerment, job satisfaction and job stress among Italian mental health nurses: an exploratory study Aim The purpose of the present study was to investigate the relationship between staff nursesõ structural empowerment, work stress and job satisfaction in two health care settings in Italy using KanterÕs Empowerment Theory. Background With the current scarcity of economic resources and shortage of nurses, it is essential to empower nurses to perform at a high level to ensure high-quality patient care. Structural empowerment is a process that can optimize use of nursing skills and professional expertise, thereby increasing job satisfaction among nurses. Method A convenience sample of 77 nursing staff employed in the Department of Mental Health in central Italy was used in this study (return rate 64%). Results Structural empowerment was significantly related to their job satisfaction (r = 0.506, P < 0.001), as was global empowerment (r = 0.62). Empowerment also had a significant negative relationship to nursesõ work stress (r = )0.28, P < 0.05). Conclusion The results of this study support KanterÕs theory of structural empowerment in an Italian nursing sample a previously unstudied population. Implications for nursing management Organizational administration must make every effort to create organizational structures and systems that empower nurses to practice according to professional standards and optimize the use of their knowledge and expertise. Keywords: empowerment, job satisfaction, nursing, work environments, work stress Accepted for publication: 16 September 2008 Introduction With the current scarcity of economic resources and shortage of nursing staff, it is essential to empower nurses to perform at a high level to ensure high-quality patient care. Structural empowerment is a process that can optimize use of nursing skills and professional expertise, thereby increasing job satisfaction among nurses. According to Rosabeth Moss Kanter (1977), there is a link between empowering work settings and organizational effectiveness. It is therefore important to understand how health organizations create structurally DOI: /j x 446 ª 2009 The Authors. Journal compilation ª 2009 Blackwell Publishing Ltd

2 Exploratory study of Italian mental health nurses empowering workplaces that provide access to the information, support and resources necessary to achieve positive organizational outcomes for both patients and health care providers. Recent legislation in Italy clarified the scope of practice in the Nursing profession, emphasizing autonomy and accountability of nurses (DM739/94, Code of Ethics Law 251/2000). This has highlighted the need for nurses to develop the appropriate skills and expertise to support autonomous professional practice. According to the professional profile outlined by the Italian regulatory body (DM739/94), nursing practice has three components: technical, relational and educational. This plurality of functions is consistent with the needs of health care organizations, whose mandates are to assist patients to solve their problems and meet their needs through the provision of high-quality individualized care. In current models of care, patients are expected to participate actively in partnerships with nurses and the health care team (Calamandrei 2000). To better meet the needs of their patients, nurses must be able to pursue their profession in an organizational climate that values and supports autonomous professional practice. Professional autonomy has been consistently linked to nursesõ satisfaction with their jobs, lower job strain and turnover (Irvine & Evans 1995). Furthermore, research has shown that structural empowerment is associated with nursesõ sense of autonomy and satisfaction with their work (Sabiston & Laschinger 1995, Laschinger & Havens 1996). Numerous studies have linked structural empowerment to increased work effectiveness and performance in nursing settings (Upenieks 2002, Laschinger et al. 2004) however, we could find no studies of nursesõ empowerment in Italy. The purpose of this study was to investigate the relationship between staff nursesõ perceptions of structural empowerment, work stress and job satisfaction in two health care settings in Italy using KanterÕs Theory of Organizational Empowerment. Theoretical framework Structural empowerment is defined as employee access to social structures within their work settings that enable them to accomplish their work in meaningful ways (Kanter 1977, 1993). Kanter has identified three dimensions of structural empowerment: the structure of opportunity, the opportunity to learn and grown and future prospects; the structure of power or the ability to mobilize resources through access to information, resources and support; and the relative proportion of similar employees or social composition of the work group. Access to these empowerment structures is facilitated through formal and informal systems within the organization. These factors are the foundation of an integrated structural model of human behaviour in the organization. Related literature Numerous studies have been conducted by Laschinger and colleagues which demonstrate a strong relationship between structural empowerment and job satisfaction in nursing (Laschinger et al. 2004, Manojlovich 2005). Park et al. (2006) also demonstrated the effects of structural empowerment on job satisfaction in a sample of Korean nurses. Access to opportunities to learn and grow in the job is particularly important to nursesõ job satisfaction (Irvine & Evans 1995). An employee can be satisfied with the basic content of the job, but may be frustrated if it does not allow one to grow or move in to roles in other areas of the organization. Access to opportunity to learn and grow is an important component of structural empowerment. Structural empowerment is also associated with nursesõ sense of autonomy and control over their practice. Sabiston and Laschinger (1995) found that nurses who considered their work environments empowering felt a greater sense of power and autonomy at work. Laschinger et al. (1997) found that more empowered nurses believed they gained autonomy from their involvement in unit decision-making processes. Numerous studies have established nurse autonomy as a key predictor of nursesõ job satisfaction (Irvine & Evans 1995). These findings have important implications in the current shortage of nursing staff as job dissatisfaction is a primary cause of nursing turnover. Finally, workplace empowerment has also been linked to stress and burnout among nurses (Laschinger et al. 1999, 2001, Cho et al. 2006). Laschinger et al. (2006) examined the impact of empowerment on person-job fit and work engagement/burnout among staff nurses. The study showed that empowering leaders can enhance person-job fit and prevent burnout. Manojlovich (2007) notes that nurses who feel powerless and dissatisfied with their jobs are particularly susceptible to burnout and depersonalization. In summary, there is evidence in the nursing literature that empowerment is significantly related to nurse ª 2009 The Authors. Journal compilation ª 2009 Blackwell Publishing Ltd, Journal of Nursing Management, 17,

3 M. Lautizi et al. autonomy, stress and job satisfaction. However, the majority of this research has been conducted in North American settings. It is important to investigate whether or not KanterÕs theory is generalizable to other populations of nurses in other countries. Therefore, we tested two hypotheses in a sample of Italian nurses in a mental health setting in central Italy: Staff nursesõ workplace empowerment is positively related to their job satisfaction and negatively related to stress experiences at work. Staff nurses with high levels of empowerment and low work stress are more satisfied with their jobs. Methods Design and sample We used a descriptive-correlational survey design in this study. A convenience sample of 120 nursing staff employed by the Department of Mental Health in central Italy was surveyed. Data were collected in the spring of Nurses worked on two hospital wards (35%) and seven territorial health agencies (65%) that provide services in seven different municipalities. The final sample consisted of 77 nurses who completed the questionnaires (return rate 64%). Most (66.7%) were female, averaging 42 years of age, 19 years of nursing experience and diploma-prepared (91%) (5% had a BSN). Most worked full time (94%) in unionized environment (57%), 47% on fixed shifts within a team model of care (69%). Measurement All measures used in this study have been used in previous studies of nurse empowerment. These measures were translated into Italian for this study. The CWEQ II (Laschinger et al. 2001) consists of 19 items which measure the six empowerment structures described by Kanter (opportunities, information, support, resources, formal and informal power). The items on each of the six subscales are summed and averaged to create scores ranging from 1 to 5. These six subscales are then added to create a total empowerment score (range 6 30). High scores represent higher perceptions of empowerment. Scores ranging from 6 to 13 represent low levels of empowerment, 14 to 22 moderate empowerment and 23 to 30 high levels of empowerment. The construct validity of CWEQ II was established in a confirmatory factor analysis that revealed a good match of the factor structure (v 2 = 279, df = 129, CFI = 0.992, IFIs = 0.992, RMSEA = 0.054). CWEQ II scores correlated highly with the measure of global empowerment (r = 0.56), providing further evidence of construct validity (Laschinger et al. 2001). Cronbach alpha reliabilities for the CWEQ-II subscales have been excellent (range ) ( program.html), as has that of the global empowerment measure (range ). In this study, the alpha reliabilities of the translated subscales were acceptable, ranging from 0.67 to A two-item global empowerment scale was used for construct validation purposes. Items are summed and averaged to create a score ranging from 1 to 5. A positive correlation between this score and total structural provides evidence of construct validity for the structural empowerment measure. In this study, the CWEQ-II was significantly related to global empowerment (r = 0.36, P < 0.05), providing some support for the construct validity of the translated instrument. A modification of Hackman and OldhamÕs (1975) job satisfaction scale consisting of four items rated on a five-point Likert scale was used to measure nursesõ overall job satisfaction. This scale has demonstrated acceptable reliability and validity in nursing studies (Laschinger et al. 2001). The alpha reliability for this scale was Nurses were also asked to rate on a fivepoint scale the degree of stress they experienced at work. Finally, a demographic questionnaire was also included in the questionnaire package. Data analysis Descriptive statistics, correlational and multiple regression analyses were performed using SPSS version 13.0 (SPSS Inc., Chicago, IL, USA). Cronbach alpha reliability analyses were performed on all scales and subscales. Descriptive statistics The means and standard deviations of the study variables are presented in Table 1. Overall, nurses did not consider their workplace to be highly empowering, similar to, but slightly lower than studies of North American nurses (mean = 14.60, SD = 4.21). Contrary to North American studies, these nurses reported greatest access to resources (typically the lowest empowerment in previous research). Access to information and opportunities to learn and grow were the least empowering conditions in their work settings (mean = 2.26, SD = 0.94 and mean = 2.38, SD = 0.85, respectively). The latter is typically the highest-rated source of empowerment in the nursing literature. A more detailed analysis of nursesõ responses to the 448 ª 2009 The Authors. Journal compilation ª 2009 Blackwell Publishing Ltd, Journal of Nursing Management, 17,

4 Exploratory study of Italian mental health nurses Table 1 Means, standard deviations, CronbachÕs alphas and correlations of variables Variable M SD Alpha Total empowerment Opportunities Information Support Resources Formal power Informal power Global empowerment Job satisfaction Work stress NA )0.28 )0.09* )0.17 )0.29 )0.19 )0.03* )0.07* )0.15 )0.37 *P > empowerment items is displayed in Table 2. Global empowerment scores also were lower than those reported in the nursing literature (mean = 2.25, SD = 0.98). Nurses reported relatively low levels of job satisfaction (mean = 2.39, SD = 0.83) in comparison to other studies in North America. Surprisingly few workers openly expressed professional dissatisfaction, but 70% stated they were interested in opportunities to seek another job. Finally, nurses reported moderate levels of stress in their worklife. Test of the hypotheses As would be expected in KanterÕs theory, nursesõ perceptions of structural empowerment were significantly and positively related to their job satisfaction (r = 0.506, P < 0.001), as was global empowerment (r = 0.62). These results support the first hypothesis. The results are remarkably similar to previous findings in the nursing literature, primarily in North America. Job satisfaction was significantly related to all components of structural empowerment, most strongly to access to support (r = 0.51) and opportunity to learn and grow (r = 0.51), and least strongly to access to information (r = 0.30 and formal power (r = 0.31). The pattern of relationships among elements of structural empowerment and job satisfaction is presented in Table 1. These findings are also consistent with previous research. Empowerment was also significantly related to nursesõ work stress (r = )0.28, P < 0.05). Work stress was most strongly related to a lack of perceived access to support (r = 0.29) and resources (r = 0.19) in their workplace. These results are similar to previous research. As predicted in the second hypothesis, high levels of empowerment and low work stress were significant independent predictors of job satisfaction (R 2 = 0.30, F = 15.06, P < 0.001). Empowerment was a relatively stronger predictor (b = 0.26) as compared with b = 0.13, for work stress P < Discussion of results The results of this study support KanterÕs theory of structural empowerment in an Italian nursing sample a previously unstudied population. Numerous studies conducted by Laschinger and other researchers using KanterÕs theory have shown that there is a strong relationship between high levels of structural empowerment and job satisfaction. Our results corroborate these findings and provide further evidence that the structural and social factors in the workplace are important conditions for empowering employees. The relationship between structural empowerment of Italian nurses and job satisfaction was of similar magnitude to correlations found in previous research in North America settings, adding further support for the generalizability of KanterÕs work empowerment theory. These findings corroborate those of Cortese (2007) who found that supportive work environments were important for Italian nursesõ job satisfaction. Nurses in this study reported somewhat lower perceptions of structurally empowering conditions (opportunities, information, support and resources). However, contrary to previous research, Italian nurses reported lower levels of access to opportunity to learn and grow and greater access to resources. Nurses did not consider their work to be challenging and few felt they were able to make optimal use of their knowledge and expertise (Table 2). Most reported little support for innovation and did not think their work was highly visible in the organization. These results suggest that nursesõ jobs may be focused more on the technical component of nursing practice and that more work needs to be done to address the relational and educational components described in the definition of nursing ª 2009 The Authors. Journal compilation ª 2009 Blackwell Publishing Ltd, Journal of Nursing Management, 17,

5 M. Lautizi et al. Table 2 NursesÕ perceptions of empowerment and job satisfaction None Some A lot 1 (%) 2 (%) 3 (%) 4 (%) 5 (%) Opportunity Challenging work The chance to gain new skills and knowledge on the job Tasks that use all of your own skills and knowledge Information The current state of the hospital The values of top management The goals of top management Support Specific information about things you do well Specific comments about things you could improve Helpful hints or problem solving advice Resources Time available to do necessary paperwork Time available to accomplish job requirements Acquiring temporary help when needed Job activities scale The rewards for innovation on the job are The amount of flexibility in my job is The amount of visibility of my work-related activities within the institution is Organizational relationship scale Collaborating on patient care with physicians Being sought out by peers for help with problems Being sought out by managers for help with problems ` Seeking out ideas from professionals other than physicians, e.g. physiotherapists, occupational therapists, dieticians Global empowerment Overall, my current work environment empowers me to accomplish my work in an effective manner Overall, I consider my workplace to be an empowering environment Global job satisfaction I feel very satisfied with my job I feel that my coworkers are satisfied with their jobs I would like to stay here until I retire The hospital provides a supportive work environment practice by the national regulatory body. Italian nurses in CorteseÕs (2007) study strongly valued professional autonomy and opportunities for professional development. When nurses are not allowed to practice according to professional standards they become frustrated and begin to consider leaving the organization. This contributes to the shortage of nurses in the organization and results in costly recruitment and replacement processes. Furthermore, patient care quality often suffers when nurses are dissatisfied and there is frequent changeover in nursing personnel on the unit. Our results provide direction for changes based on the application of KanterÕs theory that can be implemented by hospital management to improve nursesõ work. Job satisfaction is an important element of nursing worklife, essential for retention of nurses and ultimately related to patient satisfaction (Leiter et al. 1998). Nurses in this study were not highly satisfied with their jobs and satisfaction was related to the amount of opportunity to learn and grow in their work settings and the amount of support they received. Kanter argues that there are various types of job satisfaction that arise, arising from different situations and conditions. One source of satisfaction is from the rapport established with patients and colleagues through the practice of nursing. Another source of satisfaction is the possibility for advancement, progress and growth in the working environment. When the possibility of progress is limited or absent, nurses may only obtain satisfaction from working with patients and colleagues, but will be frustrated by a lack of prospects for professional growth, leading to feelings of being ÔstuckÕ. This may account for nursesõ wishes in this study to transfer out of their current jobs despite their reports of moderate levels of empowerment and satisfaction. Our results show that having opportunities for professional growth and 450 ª 2009 The Authors. Journal compilation ª 2009 Blackwell Publishing Ltd, Journal of Nursing Management, 17,

6 Exploratory study of Italian mental health nurses learning is particularly important for these nurses satisfaction with their work suggesting that this empowerment strategy would be helpful in this setting. Support for professional development activities, such as inservice professional development activities or formal continuing education programmes are examples of helpful strategies. However, in the Italian nursing system, career advancement in terms of promotion to management positions is strictly based on seniority, rather than rewards for innovative activities engaged in by nurses. This means that personal and professional development of new skills and expertise are the only means of career development by Italian nurses, which could increase feelings of being stuckõ, a disempowering condition according to Kanter (1977). NursesÕ experiences of work stress in combination with workplace empowerment were also related to job satisfaction in this study. This is consistent with findings in previous research in North America (Laschinger et al. 2001). The results suggest that higher levels of empowerment may offset the amount of work stress experienced by nurses. The significant relationship between stress and access to support and resources suggest that these empowerment structures are particularly important to managing stress in Italian nursing workplaces, just as they have been shown to be in North American settings (Laschinger & Finegan 2005, Davies et al. 2006). Limitations of the study The use of a convenience sample within one health care organization in Italy limits the generalization of the findings to other Italian nursing settings. Subsequent studies on nurse empowerment should be conducted with a larger more representative sample. Nevertheless, the sample used in this study had sufficient statistical power to detect significance among hypothesized relationships, suggesting the sample size was adequate for this purpose. In future research, larger samples would allow more sophisticated statistical analyses. As this was the first study we know of to examine empowerment and satisfaction of Italian nurses, we are not able to compare our results to other nursing settings in Italy. However, the psychometrics properties of the translated measures are satisfactory and consistent with those established in the literature. The low return rate may be because of the resistance of busy nurses whose work context is stressful, which is the case in mental health settings in this region. This clinical area is frequently under-staffed, leaving less time for participation in nonclinical activities, such as, research. It would be interesting to conduct another study that includes measures of psychological empowerment in addition to using CWEQ II to obtain a more comprehensive understanding of Italian nursesõ empowerment experiences at work. Conclusions Empowering nurses is both a challenge and a necessity. It is unthinkable in todayõs organizational health contexts, which emphasize principles of effectiveness, efficiency, quality, and public accountability in a more consumer aware society that nurses work in settings that limit their control over their practice. With organizations coping with major changes and scarce resources, new solutions are needed. Empowerment is a promising approach in this context to meet demands of consumers and add value to the activities of staff who aspire to autonomous practice and professional growth. To ensure high-quality patient care, nurses in this context must be engaged in a lifelong learning process to continuously improve their knowledge and skills to be active contributors to the patient care delivery process. However, administrators must make every effort to create organizational structures and systems that make it possible for nurses to practice according to professional standards and optimize the use of their knowledge and expertise. 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