Running head: NURSING EMPOWERMENT AND LEAN COMMUNICATION

Nursing empowerment and Lean communication

Jennifer C. Zayd
The University of Saint Mary

Abstract

Running head: NURSING EMPOWERMENT AND THE LEAN COMMUNICATION

Nursing empowerment is anecdotally touted as a way to attract and retain highly qualified
nurses. The American Nurses Credentialing Center (ANCC) requires that hospitals structurally
empower nurses by having decision-making structures present ("ANCC," 2016, para. 2). Most
hospitals wishing to become a Magnet organization often start shared governance counsels which
can be costly and time consuming. One alternative to shared governance is utilization of a Lean
Communication Board. One organization has implemented a Lean Communication Board on one
of their units. In order to determine whether the Lean communication board is an effective
alternative that empowers nurses a survey utilizing a modified-Likert scale was developed. The
survey attempted to determine whether nurses within the organization truly wanted to be a part of
the decision-making process and whether the nurses on the unit with the Lean communication
endorsed higher feelings of empowerment than nurses on three other similar units within the
organization.
Based on the results of the informal study, nurses wish to be empowered but due to the small
participation rate, specifically from the unit with the Lean communication board, the utilization
of the Lean communication board was not shown to improve nurses perception of
empowerment.

Nursing empowerment and Lean communication

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The empowerment of nurses has become an important factor in the realm of nursing as it
has been frequently claimed that empowered nurses tend to be more engaged and report greater
job satisfaction than nurses who feel powerless (Cicolini, Comparcini, & Simonetti, 2013). With
a shrinking workforce, there is a growing need to attract and retain high performing nursing staff.
Empowering nursing staff has been shown to assist in retaining these qualified staff members
and leads to higher engagement amongst employees. To empower someone means to give
power or authority to; authorize, especially by legal or official means ("Empower," n.d., p. 1).
Empowerment has been highly linked to satisfied nurses, so much so, that the American Nurse
Credentialing Center (ANCC) has included it as a requirement for hospitals to become Magnetdesignated.
Many studies have been conducted to better understand the ways that empowerment
impacts the workforce. Empowerment can be classified as either structural or psychological.
Structural empowerment suggests the use of management to provide access to empowerment
structures (Kanter, 1977) while psychological empowerment focuses on the experience that
employees have with these structures (Spreitzer, 1995). Kanters model of structural
empowerment is the guiding theoretical framework for this project.
Magnet Certification has made the adoption of shared governance committees a primary
means of empowering nurses as it is an integral component of the professional practice of
nurses in Magnet organizations (Rundquist & Givens, 2013). Shared governance allows nurses
to be part of the decision-making process by the formation of a council of staff nurses that meet
to make decisions in regards to the care that they provide the patients. While shared governance
has shown many positive outcomes, it can be costly to implement and requires continued interest

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and participation to remain effective in the long run (Brooks, 2006). This leads to the question,
are there any viable alternatives to initiating shared governance into an organization?
One hospital in California, for example, currently has no large scale formal process for
nurses to be involved in the decision making process. This same hospital is looking at changing
its processes by utilizing Lean methodology. Lean principles require the input of every member
of the organization which would naturally lend itself to allowing nurses to have a voice regarding
the way that care is provided (Perez Toralla, Falzon, & Morais, 2012). Lean initially started as a
production system that the Toyota Motor Corporation implemented to streamline workflow and
improve work processes (Dickson, Anguelov, Vetterick, Eller, & Singh, 2009). Lean is now
being adopted in industries outside of the automobile industry and has become a hot concept
within healthcare. A key component of Lean is the participation of organizational employees to
drive change (Perez Toralla, Falzon, & Morais, 2012).
One unit within an organization in California has implemented an interactive presentation
board called a Lean communication board. This board allows employees to initiate suggestions
and follow the suggestion with the end goal being implementation. There are numerous sections
on the Lean board with some of them allowing staff direct input into the decision-making process
within the unit and some sections that are meant to allow communication amongst co-workers
and inform the staff regarding changes in hospital policies, educational opportunities, etc. An
idea chart is a key part of the Lean board. The idea chart allows the staff to write out an idea on a
sticky note and see as the idea moves from being an idea, to being something that may or will be
done. Once the idea is one that has been decided to be acted upon, the idea moves into the active
doing section of the chart. Finally, when the idea has been implemented, the sticky note with the
idea goes to the done section of the chart (Appendix A).

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Another key section of the Lean communication board allows the staff to see how their
ideas are prioritized. The Prioritization (Pick) chart allows the managerial team to provide a
visual to the staff on the likelihood of their ideas being implemented based on difficulty to
implement and the possible impact the idea will have on staff or patients (Appendix B).
A performance improvement section is included on the Lean Communication board. The
performance improvement section allows the management team to notify staff members about
changes they would like to implement and allows staff to provide input into the changes propose
so that realistic solutions can be implemented. One performance improvement project the
management tasked the staff with was trying to find ways to decrease the loud noises at night, in
order to improve patient rest. This issue was placed in the performance improvement section
which allowed staff to assist in finding a remedy to this issue.
The Lean communication board requires active participation of both employees and
management which creates a decentralized decision-making process. It allows for constant
feedback between the management team and front line staff. It is fluid, in that it can be changed
at any time to represent the needs of the unit and does not necessarily need to be exactly the
same across units. This board serves as the focus of this informal study which will assess
whether nurses on the unit where the Lean communication board is present feel more empowered
than the other acute care medical units within the organization. The hypothesis being that nurses
on the unit with the lean communication board will report higher feelings of empowerment than
nurses on five other, similar units and that nurses as a whole, within the organization, wish to be
a part of the decision making process.

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Current Evidence
Kanter (1977, 1993) introduced a model of workplace empowerment that revolves around
four organizational structures: access to information, access to support, access to resources
necessary to do the job, and access to opportunities to learn and grow. Each structure has a
particular function. Access to information requires knowledge of organizational values, policies,
and goals and also refers to the possession of knowledge and expertise required to work
effectively (Laschinger, Nosko, Wilk, & Finegan, 2014, p. 1616). Access to support suggests
frequent feedback and the guidance of supervisors, peers, and subordinates. Access to resources
includes funds, supplies, and time to support organizational goals. Finally, access to opportunity
requires challenging the workforce and providing rewards and opportunities for professional
development. Kanter (1977, 1993) suggests that these structures provide employees with overall
empowerment which equates to a fulfilled workforce. Cicolini, Comparcini, & Simonetti (2013)
found that structural empowerment must be in place for psychological empowerment to be
present. The findings of their study state that if structural and psychological empowerment are
realized, a positive correlation to improved job satisfaction is noted, which may lead to improved
patient outcomes. Laschinger et al., (2014) found that the quality of work at the unit-level is
crucial to improving individual nurses well-being and suggests that nurse managers can
contribute to a healthy work environment by empowering their workforce by making sure the
four workplace structures described by Kanter (1977, 1993) are present.
While empowerment is one of the foci of this study, it is important that Lean
methodologies be addressed to note whether or not the Lean method is conducive to an
empowered workforce in nursing. Dickson, Anguelov, Vetterick, Eller, & Singh (2009)
completed a study that looked at the effects of Lean implementation in the Emergency

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departments of four hospitals. They found that the engagement of frontline workers was crucial
to the implementation of Lean strategies and produces slow, sustained improvements. Abuhejleh,
Dulaimi, & Ellahham (2016) found involving and empowering employees in the Lean process
improved employee buy-in thereby allowing for as successful diffusion of Lean innovation
(Abuhejleh et al, 2016, p. 31).
Jones, Latham, & Betta (2013) were slightly more critical of Lean methodologies stating
that Lean management presents itself as empowering to employees but is an illusion produced to
improve employee buy-in. The basis of the articles claim comes from studying the automobile
industry and the organizations that functioned under Lean methodology.
No studies were found to suggest whether or not the utilization of a Lean communication
board improves employees feelings of empowerment. Zarbo (2012) makes mention of using
whiteboards as tools for communicating and as a visual for those doing the work as well as
those managing the reliability, consistency, and stability of the work (Zarbo, 2012, para. 17).
Zarbo (2012) concludes that a continual improvement loop, initiated by front-line employees is
one of the core principles of Lean management.
Methods
In order to gather data, an instrument that utilizes a modified Likert scale was developed.
The Nurse Empowerment Survey (Zayd, 2016) includes ten questions meant to determine staff
nurses feelings of empowerment (See Appendix C). Four demographic questions are included in
order to better sort the data with one demographic question asking what unit the nurse works on.
The instrument utilized in this research was assessed and approved for use by both the
organizations Independent Review Board (IRB), as well as an IRB associated with a University.
There was found to be no risk associated with this study. Prior to approaching potential

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participants, the directors of each unit were approached for consent to survey the nurses
employed on the unit. Four managers were supportive and approved of the study while one did
not respond to requests for a meeting to discuss the survey. Once permission was provided from
the four units ( Unit 1, Unit 2, Unit 3, & Unit 4), potential subjects were sent an email
introducing the study (Appendix D), stressing that participation was voluntary and requesting
that all replies remain anonymous. A stand was placed along with the surveys to reiterate what
was sent in the email. Once participants were done with their survey, they placed it in a plain
white secured ballot box. The survey was administered over the course of one week.
Six medical/surgical/telemetry units were considered for inclusion in the study with four
units agreeing to allow their staff to be surveyed. These units were included as they were all of
similar make-up and purpose with all being medical/surgical floors with similar numbers of
employees. Specialty care areas were not included due to the different make-up of each specialty
care area. Individual inclusion criteria included all staff nurses working on one of the four units
that agreed to participate in the survey. 170 nurses were eligible for participation in the survey. A
total of 56 surveys were returned (33%). 15 surveys were thrown out as the criteria of being a
nurse on one of the four eligible units were not met (27%). 41 surveys were utilized for inclusion
into this study, which gave the study a participation rate of 24 %. The units included in the study
will be referred to in this paper, as Unit 1, Unit 2, Unit 3, and Unit 4. Appendix E provides a
breakdown of the participation rates of each individual unit.
Data was organized based on the questions asked on the survey as questions 4, 5, & 6
which attempted to answer the question of whether nurses wished to be a part of the decision
making process. This data was based on all responses without narrowing the responses down by

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unit. All other questions were meant to determine whether the nurses on the Unit with the Lean
communication board (Unit 1) felt more empowered than nurses on the other three units.
Result
The first goal of the Nurse Empowerment survey was to determine whether nurses within
the organization wanted to be empowered by being a part of the decision making process. When
asked whether they would like to be a part of the decision making process 90.25% either agreed
or strongly agreed that they want to have a say in how patient care is delivered (Figure 1).

Figure 1. Results of survey question four.

Nurses were then asked whether they had ideas to share, that they thought could improve
care delivery with many nurses (73.13%) suggesting that they had ideas that they wanted to share
that would improve care delivery (Figure 2).

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Figure 2. Results of survey question five

Finally, nurses were asked whether they felt like it was important that their opinions were
heard. The survey results once again showed that it is important for nurses surveyed in this study
to have their ideas and opinions heard (Figure 3) with 87.1% stating they either agree or strongly
agree with that statement.

Figure 3. Results of survey question six.

The second part of the survey attempted to determine whether nurses on the unit with the
Lean Communication Board (Unit 1) felt more empowered than the nurses on the other three
units (Unit(s) 2, 3, & 4). Question 1 asked participants whether they felt that their management

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team valued their opinion. 43.9% agreed or strongly agreed with that statement, while 36.58%
disagreed. 19.5% remained neutral.
Question two asked participants whether their management team actively sought out their
input regarding change. Respondents were split with 36.59% stating that their ideas were sought
out while 36.59 stated that their ideas were not sought out. 26.83% remained neutral. Question
three asked participants if they felt that their management team encouraged idea sharing. The
majority of nurses suggested that their management team does encourage idea sharing (48.78%)
while 17.07 % remained neutral, and 34.15% either disagreed or strongly disagreed with that
statement. When asked whether their unit had a formal way of sharing ideas. Most participants
were neutral to that statement (41.46%) while 36.95% stated that there was no formal way of
sharing ideas. Interestingly, the unit with the Lean communication board was split with one
participant strongly agreeing that there was a formal way to share ideas while the other
participant remained neutral. Question eight asks the survey participants whether their
management team welcomed their ideas with 48.79% endorsing that statement and 34.15%
disagreeing. The rest (17.06%) remained neutral. Question nine was meant to determine whether
subjects felt that if they presented their leadership with an idea, it could result in change. Due to
the ambiguity of the question, it was determined to be unlikely to assist in determining whether
nurses on Unit 1 feel more empowered than nurses on the other units. Finally, the tenth question
asked nurses whether they have seen positive changes from employee input. While many nurses
remained neutral on the subject (31.71%), 19.52% disagreed with that statement, and 48.78%
suggested that they had seen positive change from employee input. Appendix E shows the survey
questions as well as the aggregate results.

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Discussion
The end results of the study showed that nurses within the organization wish to be a part
of the decision making process, which results in a more satisfied workforce (Cicolini et al.,
2013). As found in the literature review, nurses feel empowered when their input is sought out
and utilized. Regarding the impact of the Lean Communication Board, it is clear that based on
the survey results, we cannot reject the null hypothesis as the differences between unit 1, which
was the unit with the LCB, and units 2, 3, & 4 were not found to be statistically significant. It is
important to note, however, that unit 1 had the least participation in the survey which made it
hard to get a good grasp on whether or not any true differences existed. If this project were to be
completed in the future, a longer survey period as well as frequent reminders to staff would be
beneficial to increase participation. A qualitative discussion could be initiated as well to
encourage further inquiry into whether or not Lean communication boards can serve as a viable
alternative to shared governance. Dickson, Anguelov, Vetterick, Eller, & Singh (2009) completed
a qualitative study and found that frontline staff involvement was imperative to an organization
being successful when implementing Lean principles. A qualitative study by Kane et al. (2015)
concluded that engaging frontline staff and developing individual responsibility through the use
of daily huddles, visibility walls, provide the constant engagement that is necessary to ensure
that continual improvement processes are forthright in the mind of clinical staff (Kane et al.,
2015, p. 432).
Recommendations and conclusion
Nurse empowerment is an important factor when trying to hire and retain qualified
nurses. Nurses want to feel valued for the knowledge they have and the majority of nurses would
like to use their vast knowledge to improve care at the bedside. Managerial staff should actively

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seek out nurses opinions and allow nurses to have a say in the care that they provide and the
processes supporting that care.
Discounting the utilization of Lean Communication boards to engage staff would be
premature at this time as there is not adequate data to truly determine whether or not it is a viable
replacement for expensive shared governance councils. More research should be conducted in
order to determine the effectiveness and usefulness of this tool.

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References
Abuhejleh, A., Dulaimi, M., & Ellahham, S. (2016, February 3). Using Lean management to
leverage innovation in healthcare projects: Case study of a public hospital in the UAE.
BMJ Innovations, 2, 22-32. http://dx.doi.org/10.1136/bmjinnov-2016-000076
Brooks, B. A. (2006, May). Measuring nursing-shared governance. Journal of Nursing
Administration, 36, 231. Retrieved from
http://journals.lww.com/jonajournal/Fulltext/2006/05000/Measuring_Nursing_Shared_G
overnance.12.aspx
Cicolini, G., Comparcini, D., & Simonetti, V. (2013). Workplace empowerment and nurses job
satisfaction: A systematic literature review. Journal of Nursing Management, 22, 855871. http://dx.doi.org/10.111/jonm.12028
Dickson, E. W., Anguelov, Z., Vetterick, D., Eller, A., & Singh, S. (2009). Use of Lean in the
emergency department: A case series of 4 hospitals. Annals of Emergency Medicine, 1-7.
http://dx.doi.org/doi:10.
Empower. (n.d.). Retrieved from http://www.dictionary.com/browse/empowerment
Jones, R., Latham, J., & Betta, M. (2013). Creating the illusion of employee empowerment: Lean
production in the international automobile industry. The International Journal of Human
Resource Management, 24, 1629-1645.
http://dx.doi.org/http//:dx.doi.org/10.1080/09585192.212.725081
Kane, M., Chui, K., Rimicci, J., Callagy, P., Hereford, J., Shen, S., ... Pickham, D. (2015,
September). Lean manufactring improves emergency department throughput and patient
satisfaction. Journal of Nursing Administration, 45, 429-434. Retrieved from

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http://journals.lww.com/jonajournal/_layouts/15/oaks.journals.mobile/articleviewer.aspx?
year=2015&issue=09000&article=00006
Kanter, R. M. (1977). Men and women of the corporation. New York, NY: Basic Books.
Kanter, R. M. (1993). Men and women of the corporation (2nd ed.). New York, NY: Basic
Books.
Laschinger, H. S., Nosko, A., Wilk, P., & Finegan, J. (2014, April). Effects of unit empowerment
and perceived support for professional nursing practice on unit effectiveness and
individual nurse well-being: A time-lagged study. International Journal of Nursing
Studies, 51, 1615-1623. http://dx.doi.org/http//:dx.doi.org/10.1016/j.ijnurstu.2014.04.010
Magnet Model. (2016). Retrieved from
http://www.nursecredentialing.org/Magnet/ProgramOverview/New-Magnet-Model
Perez Toralla, M. S., Falzon, P., & Morais, A. (2012). Participatory design in lean production:
Which contribution from employees? For what end? Work, 41, 2706-2712.
http://dx.doi.org/10.3233/WOR-2012-0514-2706
Rundquist, J. M., & Givens, P. L. (2013, March). Quantifying the benefits of staff participation in
shared governance. American Nurse Today, 8(3), 38-42. Retrieved from
http://web.a.ebscohost.com.stmary.idm.oclc.org/ehost/detail/detail?sid=0fe68ec0-99f2409d-9505d7ec13ae0cf3%40sessionmgr4009&vid=6&hid=4214&bdata=JnNpdGU9ZWhvc3QtbGl
2ZQ%3d%3d#AN=104290837&db=ccm
Spreitzer, G. M. (1995). Psychological empowerment in the workplace: Dimensions,
measurements, and validation. Academy of Management Journal, 38, 1442-1465.
http://dx.doi.org/doi: 10.2307/256865

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Zarbo, R. J. (2012, September 1). Creating and sustaining a Lean culture of continuous process
improvement. American Journal of Clinical Pathology.
http://dx.doi.org/http//:dx.doi.org/10.1309/AJCP2QY1XGKTSNQF
Zayd, J. C. (2016). Nurse Empowerment Survey [Survey]. Unpublished instrument. Monterey,
CA.

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Appendix A

Example of an Idea Chart

17

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Appendix B

Example of a PICK chart

Appendix C

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19

Appendix C
Nursing Survey
Please rate the following statements using the following scale:
Strongly agree =5

Agree =4

Neutral =3

Disagree =2

Strongly disagree =1

1. My management team values my opinion

1 2 3 4 5

2. My management team requests my input regarding change

1 2 3 4 5

3. My management team encourages idea-sharing

1 2 3 4 5

4. I would like to be a part of the decision making process

1 2 3 4 5

5. I have ideas that I feel I can bring to my management team

1 2 3 4 5

6. It is important to me that my opinions are heard

1 2 3 4 5

7. My unit has a formal way for sharing ideas

1 2 3 4 5

8. My management team welcomes my input

1 2 3 4 5

9. I feel that my input can result in change

1 2 3 4 5

10. I have seen positive change from employee input

1 2 3 4 5

Demographic Data (Please circle your answer)

Age
18-25
26-35
36-45
46-55
(1)
(2)
(3)
(4)
How long have you been a nurse?

55 +
(5)

1-3 years
4-8 years 9-15 years
(1)
(2)
(3)
What type of degree do you hold?

16+ years
(4)

Certificate
ADN
(1)
(2)
What unit do you work on?
TW

GE

MP

(1)

(2)

(3)

MW
(4)

BSN
(3)

MSN
(4)

PhD
(5)

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Appendix D
Greetings Colleagues,
My name is Jennifer Zayd and I work as a nurse on Main Pavilion. I am currently working on my
M.S.N. and am doing an informal study regarding empowerment. I would like to have your
participation in a brief survey (Nurse Empowerment Survey) that will allow me to complete my
study. Participation is strictly voluntary and I respectfully request that you do not put your name
on the survey as I would like to keep the results anonymous. The survey will take place Monday,
July 11th until Monday, July,18th. There will be a large white box for you to place your completed
surveys in a designated area on your unit. Your feedback is very important and I thank you for
your consideration and participation.

Very Respectfully,
Jennifer Zayd

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Appendix E

Participation Rates overall and by unit

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