How to manage the staff duty roster

22 March, 2007 For nurses who are taking on management responsibilities, one of the most daunting tasks can be tackling the dreaded off duty. Here are some tips for success It is perhaps the biggest challenge of management. For although working out the off duty? offers a keen sense of power, the responsibility that comes with it can be more trouble than it is worth. How you discharge that responsibility will not only determine how popular you are with members of the team, but more importantly, how effectively your work area is resourced and therefore the level of patient care that can be given. The main aim in working out staffing levels is to provide consistent and effective nursing care to those patients for whom you are responsible. In essence, staff rosters should ensure that:

The service is delivered by competent staff in the right numbers at the right times; Team members have a reasonable workload and acceptable periods of rest betweenshifts, as outlined by the European Union Working Time Directive.

Shift-based nursing, found in both acute and community settings, poses a major challenge to a manager who has not only to take into consideration the human resources in numbers, often expressed as whole time equivalents (WTE), but also the staff mix, competencies and the needs of the patient/client group, as well as other activities to be performed during the shift. Even if you do not work in a 24/7 service, you will need to take into consideration annual leave and requests for days off, as well as other absences. What often increases the challenge is the use of many part-time staff. For example, five WTE staff nurses may comprise at least seven people. Influenced by the governments Improving Working Lives initiative, nurses are gradually being offered more flexibility to help with other commitments and promote a healthy work-life balance. We are now seeing fewer standard patterns of work, for example 10 or 12-hour shifts, and instead find nursing staff working anything from five to 37.5 hours a week, often with half shifts that relate to the length of a school day. In addition, different staff do not have the same skills and competencies. Patient needs also change, not only from day to day, but from shift to shift. There are, in addition, considerable resource issues, both in terms of available supply and budgets. Budget management is complex and varies between organisations, but it is common for staff to be funded at the mid-point of their grade. If you have many senior personnel then the actual budget needs adjusting. It is expected that, with vacancies and staff members below mid-point, these will balance out your more expensive staff. The aim of Agenda for Change is to even out over the whole year extra payments for unsocial hours such as bank holidays, but this system is

still under review. Contact your areas AfC representative if you have queries relating to the new system. When sitting down to draw up your roster, first consider:

How many weekends do staff work per month and what are the night duty expectations? Are routine shifts agreed for certain staff?

Next look at absences, for example annual leave, sickness and study leave, and mark them in. Then make a list of their grades, or AfC bands, and how many shifts each staff member usually covers. If it is your first time doing the roster, it can be very useful to refer to previous ones to identify any pattern - as long as these worked well. After that, identify the grade/skill mix of the shifts required. Certain shifts may require different grades or competencies of nurses, for example assessment days, theatre days or consultant/specialist visits. Only then are you in a position to be able to consider requests for certain shifts or days off. Rest assured that it will often be impossible to authorise all requests without further negotiation. As much as you would like to please everyone, the priorities of the service must be met within the budget. A further challenge is covering sickness absence. Most settings will build in a percentage in anticipating annual leave, study leave and short absences. However, for longer periods it is the remaining team members who must be flexible in their working practices. Financial considerations must be made before employing bank or agency staff, so you should familiarise yourself with your organisation?s policy with regard to their usage. Once you have finished filling in the roster, you will need to display it where all staff will see it. Amendments may be needed due to changing circumstances relating to the clinical setting or staff. Because you have taken time and energy to write it, you are the one who is best placed to answer any questions. The time and effort involved in completing the off duty will vary from person to person - but as a novice you should expect it to take many hours. Be sure to have all the information you require, such as requests, patterns and financial information, before you start and, where possible, arrange in advance some undisturbed time - preferably using some of your allotted admin time. Taking time and consideration to complete the process, maintaining good communication with team members, will ensure you provide an effective roster that all staff can work with, and that allows patient care to be safely delivered. Learning the secrets of doing the off duty:

Work with another person who is practised at writing rosters; Discuss the financial implications with the accountant/finance officer for your area; Attend in-house training for budget management (this may be arranged with human resources and finance departments); Allot specific administration time to the task and do not leave it until the last minute;

If you believe that there are fundamental shortfalls or problems with staffing levels or other human resources issues, arrange to discuss this with your line manager, director of nursing, human resources department or, failing that, union representative.

STAFFING IN NURSING UNITS

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Nurse managers are key to revamping and reshaping staff motivation

Renew

A staff member's lack of satisfaction with his or her work environment often yields a lack of engagement. If neglected, this lack of engagement yields turnover--all the reason for nurse managers to search for ways to spark employee motivation. Often enough, what is hindering an employee's work output are the actions--or lack of actions--of the manager. No matter which way you look at it, you, as the nurse manager, directly affect staff morale. Your body language on a stress-filled day, your expression of gratitude when an employee does more than what is asked of him or her, and your ability to discipline a worker when he or she is not performing up to standards, all tie into the overall work experience, good or bad. Your actions affect whether employees feel the urge to participate in the present and hang around in the future. But being aware of how you conduct yourself in your facility can make all the difference. Refer to the following tips for some guidance. Starting the day off right. Keep in mind the first steps you take into your facility set the tone for the rest of the day. Your arrival and the manner in which you speak to staff in these very first moments affect the mood and performance of those around you. If you are overtired, drink an extra cup of coffee. If you are frustrated, do your best to conceal it because staff will see this and avoid you. Also, instead of marching straight to you desk at the beginning of your shift, take a quick stroll around your unit and greet people. Flash a smile, walk with poise, and share your expectations with your staff before the day starts. Working employees into your schedule. Studies have shown that managers benefit by spending positive interaction time with their staff. Try to devote a part of your time each day with each person working during your shift. Depending on the size of your facility, this may not be realistic. If you cannot manage this, shoot for an hour each week. This time will allow you to develop a closer bond with staff members and also send them a message that they are an important to you as individuals.

The power of simple words. Building up employee motivation has much to do with making people feel valued. Never underestimate "please" and "thank you." Also, never miss an opportunity to tell people they are doing a great job. The nursing profession can be emotionally-draining and challenging. Even so, these simple, yet meaningful words can improve staff morale if said often enough, and at the right moments. Giving feedback to staff. Information about a staff member's work performance is an effective tool in improving it, and also in fostering engagement. People are interested in how other people perceive them and their skills in their workplace. Make staff aware when they do not perform up to par so that they have the opportunity to self-correct. Set up daily or weekly meetings to check back with them and see how they are progressing. These meetings will give you time to express what you need from your staff, and in return, they can learn how to give this to you. Focus on the future. Gaining experience is one of the largest benefits of working. Most nurses are eager to become competent in their roles so they can set out to achieve future roles. Get to know your nurses and their goals. Whether this drive is for a pay increase, or the desire to obtain a leadership or management position at your facility, take time to discuss this with them. Motivate staff to explore other areas of interest and be considerate of their plans. Staff members will be grateful for your attention to their current needs and future aspirations
2012 Motivating staff is a big part of leadership in any industry. Because of the high stress nature of staff nursing, motivation and support and proactive work environment improvement policies are very important to retain qualified nurses. In "The Five Practices of Exemplary Leadership" Nursing," authors James Kouzes and Barry Posner claim that "leadership is everyone's business," including CEOs, unit leaders, nurse managers and even nurses. Motivating nurses is one of the biggest challenges of nursing management that registered nurse Michelle Voss says can be met by introducing interactive and proactive processes and avoiding reactive responses.

Regularly Ask for Feedback

Ask for nurses' feedback about nursing issues on a regular basis. Encourage open discussion of their everyday challenges with patient care, hospital environment, work schedules and any other stressful nursing issues they are experiencing. Provide a variety of avenue to express their ideas and suggestions in a positive, proactive way, and discourage unproductive griping and complaining. Ask them what they think about the most frequent nursing challenges they deal with at meetings, through suggestion boxes, with monthly or quarterly surveys and in performance reviews. Steer requests for feedback in a positive way by asking about solutions, not just feelings or opinions.

Involve Nurses in Leadership

Give nurses an opportunity to demonstrate and experience leadership in their profession on a regular basis. Schedule nurses to lead nursing or department staff meetings, research current medical topics and share nursing experiences. Assign nurses to present small educational sessions for peer-to-peer learning about such subjects as hospital policies, nursing procedures and patient care trends and responsibilities.

Encourage mentoring partnerships by pairing senior nurses with new staff nurses for support, problemsolving and sharing experiences.

Set Up Mutual Understanding

Understanding the other person's point of view, experience and work processes, eases frustration and develops cooperation. Set up ways for staff nurses to better understand other departments such as laboratories, pharmacies, patient intake and radiology. Encourage mutual cooperation, teamwork and problem-solving rather than adversarial relationships. Regularly invite members of other departments to come to nurse meetings or stop by at the beginning of shifts to introduce themselves and discuss their departments. Developing a supportive and mutually cooperative relationship for nurses improves morale and motivates nurses.

Commit to Positive Communication

Communication styles can be motivating or demotivating in any profession, and especially so in stressful, busy nursing environments. Commit to using positive communication with nurses to develop a friendly, caring and supportive atmosphere and to provide training on positive, caring communication for staff nurses. Start nursing shifts in a positive way by greeting staff nurses at the beginning of their work day. Schedule regular one-to-one time with each nurse, whether it's daily or weekly, to listen, ask for feedback, communicate expectations, offer advice and get to know nurses and their career and work goals. Provide support for specific problems they experience; for example, if a nurse is expressing frustration with a difficult patient, assign a more experienced nurse or a particularly caring and empathetic nurse assistant to partner with the nurse on that patient's care. Or make it a point to touch base with the nurse daily on the difficult patient's progress for some stress relief. Good manners, friendly interactions and positive language motivate nurses to model the same, provide calming interactions in stressful situations and encourage good working relationships

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What Are the Different Types of Leadership Styles in Nursing?
X By Krista Sheehan , eHow Contributor

A nurse manager will utilize a specific leadership strategy.

Every day, nurses are responsible for the health and well-being of their patients. To ensure continuity of patient care, every nurse on a unit works together to achieve shared goals. This cohesive team works diligently to promote patient health, safety and recovery. To achieve this unity, the nursing manager coordinates and supervises all interactions between her team members. To do this, the nursing manager utilizes a specific nursing leadership style.

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1. Transformational Leadership
o

With the transformational style of nursing leadership, the focus is to unite the nursing manager and her employees to work toward a shared goal. Through

their united goal, all members of the team work together "to purse a greater good," according to the University of North Carolina, Charlotte. This leadership styles allows nurses to take an active role in evaluating, establishing and changing policies. By carefully observing current policies and providing feedback to their leader, nurses help promote the best actions for patient care. As explained by NursingTimes.net, the transformational style is "more highly correlated with perceived group effectiveness and job satisfaction."

Transactional Leadership
o

The transactional leadership ship style is relatively basic. According to NursingTimes.net, transactional leadership is "short-lived, episodic and taskbased." With this style of nursing leadership, the nursing manager only interacts with her employees when something needs to be done or when something is wrong. The nursing manager will inform her employees when tasks are in need of completion. She will then retreat, allowing them to complete the tasks on their own. If the manager see a need for changes or corrections, she will intervene with negative feedback. Although this leadership style is not conducive to creating a close relationship between the leader and her employees, it can be effective during specific projects or tasks.

Dynamic Leadership
o

The dynamic leadership style modeled its foundation after the nursing theory set by Ida Jean Orlando, whose nursing experience is extensive. Orlando received her Bachelor of Science degree in public health nursing and her master's degree in mental health nursing. She went on to become the director of the Graduate Program in Mental Health and Yale School of Nursing. In 1961, she published a book titled "The Dynamic Nurse-Patient Relationship," in which she introduced her leadership theory to the world. The dynamic leadership style uses the idea that the relationship between the leader and the nurse is everchanging; both parties are absolutely essential to the success of the entire nursing unit. Rather than controlling her employees, the dynamic leader simply offers direction; this allows the nurse a significant amount of control in her work.

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What leadership styles should senior nurses develop? Leadership Styles in Nursing

Leadership styles in nursing management play a very significant role in the management of a nursing facility. This article throws light on management and leadership styles practiced in the nursing profession. A nursing leader might either be a nurse manager who is assigned the obligation of handling one unit or a nurse executive who is responsible for the operations of all in-patient nursing units. Usually, a successful or effective nurse leader, typically has a repertoire of leadership skills that she employs according to situations that are being faced.

Leadership Skills in Nursing

After a nurse graduates from a nursing school and gets her Registered Nurse (RN) license, she normally possesses some fundamental leadership skills to apply to direct patient care. As she gets more experienced and advances in her post, she would be required to learn more on leadership. There are many leadership courses that are available in colleges and universities, professional education facilities, and even large public and private hospitals. It is truly crucial for a nurse to seek advice, mentoring, and coaching from a senior nurse leader who would render honest feedback regarding her leadership style.

Types of Leadership Styles in Nursing

Broadly speaking, there are two types of fundamental leadership styles, democratic and autocratic. A nurse leader who is democratically inclined would engage his nurses in decision-making and let them carry out work in an independent manner. Whereas, a directive autocrat would provide instructions without looking for inputs and superintend his nurses in a close manner. This can also be thought of as direct leadership and positive leadership. In direct leadership, the nurse leader would direct all the nurses under his command as to what to do, and see to it that it gets completed accordingly. In positive leadership, the nurse leader tries to ensure that the whole unite works as a team to get the tasks done. In positive leadership, incentives and positivity are usually used as tools.

A nurse leader who has a considerable amount of work experience would select a leadership and management style that would work best in any circumstance. For instance, he might play a democratic kind of role when it is time to purchase new equipment for his nursing section. He can arrange to buy equipment that is required by nurses, and then allow them to utilize it individually as needed. But from the other point of view, he might act as a directive autocrat when dealing with less experienced nurses, giving only one-sided instructions, while he closely oversees their work. Nurse leaders most importantly

need to be very stress and tension-free while managing things, as they work in a critical life and death situation where every moment counts, and where temperamental or emotional behavior is not accepted. They need to be able to fully concentrate on what they do, as it may be a question of someone's life and health.

Some Considerations of Leadership Styles in Nursing

A nurse leader might change his leadership style according to the age and expertise of nurses working under his supervision. There can be many cases where veterans would like to share their hard-earned expertise with new recruits who are in responsible positions, whereas younger and less-experienced nurses might benefit from close supervision along with sufficient guidance and feedback. Nursing has veered towards a shared model of management which involves nurses in decision-making. In this leadership model, a nurse leader employs a democratic style of leadership, encouraging nurses to actively get involved in medical decision-making activities along with monitoring their patient results.

This is in essence about leadership styles in nursing, however, a nurse manager may change his style according to situation and the way nurses respond to his instructions. His/her style may also change according to situational demands of the medical facility. Effective leadership would certainly make nursing professionals work in the best possible manner. By Stephen Rampur29 August, 2008

Senior nurses are likely to engage in a range of leadership activities in their daily routine. Some will naturally adopt an effective leadership style, while others may find the concept of leadership or seeing themselves as leaders difficult to understand. Effective leadership is critical in delivering high-quality care, ensuring patient safety and facilitating positive staff development.

Frankel, A. (2008) What leadership styles should senior nurses develop? This is an extended version of the article published in Nursing Times; 104: 35, 23-24.

Author Andrew Frankel, MSc, BA, PGCMS, RNM, DipN, is hospital director, Churchill Gisburn Clinic, Lancashire.

Introduction

This article outlines the characteristics of an effective leader, the political context and various leadership activities for senior nurses. It also discusses mentorship, different leadership models and the process of professional socialisation.

For the purposes of this article, senior nurses are defined as practitioners with additional postqualification education, skills and experience who work within the nursing team providing a day-to-day, hands-on, visible presence.

Leadership can be defined as a multifaceted process of identifying a goal or target, motivating other people to act, and providing support and motivation to achieve mutually negotiated goals (PorterOGrady, 2003). In the daily life of a senior nurse, this could refer to coordinating the day/night shift and the team of nurses and support staff on duty under the direction of that nurse. The successful operation of the shift, staff morale and managing difficult or challenging situations depends largely on the senior nurses leadership skills.

It is important to appreciate that leadership roles are different from management functions. In Stephen Coveys (1999) book The Seven Habits of Highly Effective People, he quoted Peter Drucker as saying: Management is doing things right; leadership is doing the right things. Management is efficiency in climbing the ladder of success; leadership is about determining whether the ladder is leaning against the right wall. This suggests that management is about tasks, whereas leadership is about perception, judgement, skill and philosophy. We could infer from this that it is much more difficult to be an effective leader than an effective manager.

Characteristics of an effective leader Leaders are often described as being visionary, equipped with strategies, a plan and desire to direct their teams and services to a future goal (Mahoney, 2001). Effective leaders are required to use problem-solving processes, maintain group effectiveness and develop group identification. They should also be dynamic, passionate, have a motivational influence on other people, be solution-focused and seek to inspire others.

Senior nurses must apply these characteristics to their work in order to win the respect and trust of team members and lead the development of clinical practice. By demonstrating an effective leadership style, these nurses will be in a powerful position to influence the successful development of other staff, ensuring that professional standards are maintained and enabling the growth of competent practitioners. In a study by Bondas (2006), leaders who were described as driving forces were admired. They were regarded as a source for inspiration and role models for future nurse leaders.

Leadership for senior nurses is primarily about the following: making decisions; delegating appropriately; resolving conflict; and acting with integrity. The role also involves nurturing others and being aware of how people in the team are feeling by being emotionally in tune with staff.

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The above functions are the core elements necessary to connect leadership with the effective development of other team members. This is largely achieved by working alongside them in a mentoring and coaching role. A good and successful leader will seek to develop other staff through their leadership. Saarikoski and Leino-Kilpi (2002) found the one-to-one supervisory relationship was the most important element in clinical instruction. Research also suggests that mentorship facilitates learning opportunities, helping to supervise and assess staff in the practice setting. Terminology frequently used to describe a mentor includes: teacher; supporter; coach; facilitator; assessor; role model; and supervisor (Hughes, 2004; Chow and Suen, 2001).

Within my own organisation we often refer to the phrase dont just tell me - show me, which illustrates the need for management instructions to be supported by clear leadership and supervision. It is recommended that staff are first shown how to perform a task and then supported to complete it.

A culture based on continual learning through support and best-practice methods will empower and motivate staff. Dynamic clinical leaders and supportive clinical environments are essential in the development and achievement of best practice models.

Key factors described as effective in nurturing transformational clinical leaders are: provision and access to effective role models; mechanisms for mentoring and clinical supervision; provision of career pathways; intentional succession planning; organisations that value clinical competence; and promotion of centres of excellence (Borbasi and Gaston, 2002).

Political context

Nurse leaders need to be able to respond to an ever-changing healthcare environment, including organisational expectations and changes to local and national policy. I do not know of any clinician or manager who would dispute that nursing roles are changing. These roles have become more specialist, autonomous, accountable and focused on outcome, with both positive and negative consequences for the profession. Consumers and purchasers of healthcare services have greater expectations of higher standards, particularly in relation to nursing care.

Nurse leaders must demonstrate resilience in responding to change and supporting others to embrace this in a positive way. Effective leaders should be capable of reframing the thinking of those whom they are leading, enabling them to see that changes are not only imperative but achievable.

Senior nurses need to find ways of becoming involved in organisational decision-making on issues impacting on clinical care such as: developing policy; workforce planning; departmental business planning; and clinical and corporate governance. Sorensen et al (2008) advocate that senior nurses must develop constructive processes through which they become accepted as equal team members. They also need to design workplace systems that underpin good patient outcomes, evaluate nursing expertise and represent nursing interests in corporate decision-making forums.

Leadership activities of senior nurses

Senior nurses should be able to develop other staff by enabling them to apply theory to practice and encouraging them to test new skills in a safe and supportive environment. This, again, is an example of where leadership activities combine with developmental ones to create competent practitioners through practice-based learning.

These nurses should adopt a supportive leadership style with mentorship, coaching and supervision as core values. Constable and Russell (1986) showed that high levels of support from supervisors reduced emotional exhaustion and buffered negative effects of the job environment. Consequently, it would be particularly beneficial for supervisors to provide emotional support to nurses and give them adequate feedback about performance to increase self-esteem (Bakker et al, 2000). Senior nurses should also apply leadership skills in encouraging staff to use critical reflection to facilitate new understanding.

In the ward environment, there can be tensions between professional disciplines. Resolving these and building effective relationships between multidisciplinary team members is a test of senior nurses leadership abilities. With nurses becoming more autonomous decision-makers, this must inevitably lead to revising the relationship between professional roles.

Senior nurses also have a leadership role in facilitating their organisations staff support and development programme, which should aim to reduce stress, burnout, sickness and absenteeism among colleagues. Supervisors have a significant influence on employees personal and professional outcomes. Bakker et al (2000) reported that senior nurses can buffer the effects of a demanding work environment on staff nurses by thoughtfully maintaining a leadership style that supports staff needs.

A successful leader will see each person as an individual, recognising their unique set of needs, as not everyone will perform at the same level or respond in the same way to environmental stressors or workplace pressure. Leaders need to support staff in ways in which individuals recognise as being useful.

In the same way, staff will be motivated by different factors. Leaders must focus on the needs of individual staff and use motivational strategies appropriate to each person and situation. They must seek to inspire demotivated staff and maintain the motivation of those who are already motivated. Leadership seeks to produce necessary changes in demotivated staff by developing a vision of the future and inspiring staff to attain this. Leadership is the driving force of the work environment and directly affects staff motivation and morale. West-Burnham (1997) argued that leaders should seek to improve on current practice, and use their influence to achieve this. This includes working within the team to develop goals and a feeling of shared ownership to achieve excellence in clinical practice.

Mentorship

Different people are motivated in different ways. Therefore, leaders must use strategies that individuals find motivating to empower them and highlight the importance of the nursing role.

One method of achieving this is through the process of structured mentorship. I believe that mentorship should foster ongoing role development and be based on the acquisition and mastery of new skills.

Senior nurses should take time on every shift (between five and 30 minutes) to be involved in some form of mentoring activity, which should then be recorded in staff members learning log.

The learning log is a simple, task-specific recording method used as documented evidence that mentorship has been given on a particular area of work activity. The staff member participates in the completion of their log, which briefly records:

The nature of the activity being coached;

Strengths and weaknesses in performing the activity;

Coaching intervention;

Future goals. It is important that staff members do not feel micromanaged. Learning logs must be viewed as a mentorship tool, rather than a management one. The log is merely used to remind and refresh the mentor and staff member about what has been achieved between the last formal clinical supervision session and the next. The learning log will be used for reflection purposes to form the basis of a more comprehensive supervision discussion.

Leaders, in their capacity as mentors, must ensure that more junior staff have the freedom to seek information, through an open exchange of opinions and ideas. Staff should also be given the opportunity to show initiative, thus promoting confidence in decision-making and underpinning knowledge and competence in their own skills. The goal of mentorship should be to create a stable and supportive environment which encourages professional growth through effective role modelling. Murray and Main

(2005) argued that the notion of role modelling is seen as a traditional expectation of less experienced nurses learning from more experienced ones.

Leadership models

There are a number of useful models to help to guide senior nurses in leading other staff. The two most common are transformational and transactional models (Bass, 1985; Burns, 1978).

The effects of transactional leadership are short-lived, episodic and task based, with the transactional leader only intervening with negative feedback when something goes wrong. This form of leadership would have a place where there is a specific short-term directed project or piece of work to be completed.

In a ward, it is more desirable to identify a leadership model that offers longevity in the relationship between senior nurses and junior colleagues. The transformational model is more complex but has a more positive effect on communication and teambuilding than the transactional model (Thyer, 2003). Transformational leadership shapes and alters the goals and values of other staff to achieve a collective purpose to benefit the nursing profession and the employing organisation. Bass (1985) found that transformational leadership factors were more highly correlated with perceived group effectiveness and job satisfaction, and contributed more to individual performance and motivation, than transactional leaders.

Adair (2002) proposed a different model. This is the three-circle model of strategic leadership, with the circles being the needs of the task, the individual and the team (Fig 1).

Adair believes that knowledge or expertise alone is not enough to lead; however, without it, leadership is impossible. Leaders should be aware of both group and individual needs, and should harmonise them to support common goals.

Each of the three needs in the model interacts with the others. One must always be seen in relation to the other two (Adair, 2003). This is a democratic model of leadership, in which there is consideration for the opinions of those who have to carry out the task. Individuals and groups are involved in decision-

making processes concerning their work. The valuing of people, their knowledge, experience and skills is central to this model.

Leadership models are a useful tool for senior nurses and help to put the function of leadership activity into perspective. These nurses should not be concerned about using concepts from various models and developing an eclectic strategy. The models should be used as a framework on which to build an effective leadership style which suits the individual leader and those whom they are leading.

Professional socialisation

Supervised learning in clinical practice fosters emotional intelligence, responsibility, motivation and a deeper understanding of patient relationships and nurses identity and role (Allan et al, 2008).

For care standards to improve, attention must be paid to improving post-registration education and practice development. This should include clarifying role expectation and developing a professional identity. Professional socialisation is a learning process that takes place in a work environment, of which junior nurses are an integral part. Effective leaders will generate opportunities which create potential for professional self-development for junior staff. It is during this socialisation period that junior nurses develop opinions, attitudes and beliefs about their role which form the basis of professional growth. The role-modelling behaviour of senior nurses during this process is critical in transmitting appropriate professional values from one generation of nurses to the next.

The role of senior nurses is dynamic and multifaceted. Nurse leaders in practice settings have unique opportunities to influence and even create the environment in which professional nursing practice can flourish. Marriner-Tomey (1993) suggested that, in this highly influential role, nurse leaders have a major responsibility to change behaviour to provide an environment that supports the preparation of competent and expert practitioners. It is part of nurse leaders role to serve as a model in providing effective socialisation experiences that impart the appropriate values, beliefs, behaviours and skills to staff.

Better outcomes for patient care

Ultimately, a goal of any healthcare organisation should be to influence the quality of patient care through good nursing leadership. Good leaders should encourage junior staff to gain a better understanding of patients and their needs and values. Overall, these strategies will lead to increased patient satisfaction, more effective nurse-patient relationships and quicker recovery times.

Empowered nurses are eager to implement evidence-based practice. They are highly motivated, well informed and committed to organisational goals, and thus deliver patient care with greater effectiveness (Kuokkanen and Leino-Kilpi, 2000).

Good leadership could produce better patient outcomes by promoting greater nursing expertise through increased staff ability and a new level of competence. Aiken et al (2001) argued the hospital practice environment has a significant effect on patient outcomes. Junior nurses should be encouraged to seek maximum rather than minimum standards, and be expected to achieve and maintain high-quality benchmarks.

Conclusion

This article has highlighted the essential leadership role that senior nurses have in developing skilled and competent staff. Leadership behaviour has a great impact on staff. Senior nurses must acknowledge the importance of their role, recognising that junior staff rely on their leadership in developing their own professional skills and capability.

These nurses must use their leadership behaviour to positively influence organisational outcomes and need to appreciate the inter-relationship between developing nursing practice, improving quality of care and optimising patient outcomes. Healthcare organisations need nurse leaders who can develop nursing care, are an advocate for the nursing profession and have a positive effect on healthcare through leadership.

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Thyer, G. (2003) Dare to be different: transformational leadership may hold the key to reducing the nursing shortage. Journal of Nursing Management; 11: 73-79.

West-Burnham, J. (1997) Leadership for learning-reengineering mind sets. School Leading Ability and Management; 17: 2, 231-244.

Have your say Empower Your Nurses! --------------------------------------------------------------------------------

Emergency preparednessMedical Home Learning Session Nurse empowerment Posted: March 30, 2011 | Author: Houghton Lee | Filed under: Work | Tags: leadership, nursing |Leave a comment My team began work on a nurse empowerment plan after we completed the IHI improvement skills training. First, it is important to define empowerment: to equip or supply with an ability. In our case, my main responsibility as a good and effective leader would be to support my team members in performing their best work.

As a start, I conducted a team development survey of my nurses to examine what changes we should make at our workplace and within ourselves. The SimplerWork-Index slides provided my inspiration for this process: our next step will be..taking steps that lead to easier and more satisfying work.

I have also identified that the primary goals for my department are improving nurse coverage and employee satisfaction. Appreciable examples of initial actions we will do include providing an in-house stationery supply and having upcoming maternity coverage in place. The bigger challenge for me is to empower my employees to take ownership (to take part in the decisions that affect their day-to-day work and working conditions) of their work satisfaction. It takes moral courage for anyone and everyone to prioritize and advocate for what is important in work and life (everyone should read Stephen Coveys The 7 Habits of Highly Effective People).

I will be developing my team nurse empowerment plan further. Yes, I as a leader can and should provide the tools and support for my team.

Nursing is a dynamic profession in which nurses are increasingly being given greater responsibility and providing more complex nursing care.

eHowCareersNursing Education & CertificationHome Health Nurse TrainingNursing & Empowerment Concepts & StrategiesX Analysis of Concept Mapping in Nursing Education Must See: Slide Shows

Role of Feminist Theory in Nursing How to Use Performance Evaluation Tools in Nursing Nursing & Empowerment Concepts & Strategies X S. Herlihy S. Herlihy has been a freelance writer since 2001. Her work has appeared in many publications, including "USA Today," "The Womens Independent Press," "Big Apple Parent" and "ComputorEdge Magazine." Herlihy earned her Bachelor of Arts degree from the City University of New York.

By S. Herlihy, eHow Contributor Providing nurses with a means of empowerment is one way of encouraging effective medical care. Nurses serve important roles in the provision of efficient health care. A well-trained nurse can help patients recover more quickly and make sure that potential medical problems are addressed before they worsen. Attracting candidates to the profession and keeping those already employed on the job can help make health care providers more effective. Empowering nurses is one way to do so.

Other People Are Reading Analysis of Concept Mapping in Nursing Education Role of Feminist Theory in Nursing Print this articleAutonomy Promote autonomy. Make staff members feel as if they are important members of any health care team rather than merely cogs in an impersonal wheel. Allow staff members preference when deciding shifts. A night owl may prefer to work evenings while a more morning-oriented person prefers to work earlier in the day. Provide a choice of uniforms and other required clothing such as shoes and pins. Make all rules pertaining to a nurse's job clear before she's hired. Provide a booklet that outlines her duties, responsibilities and expectations. If changes are made notify all staff members immediately.

Educational Opportunity

Provide educational opportunities. Help nurses maintain and increase their fund of knowledge. Encourage nurses who have a licensed practical nursing certificate to earn an associate or bachelor's degree and become a registered nurse. Give nurses who already have a BSN (bachelor's of science in nursing) the opportunity to take classes and earn a specialized certification. Many states require nurses to take annual classes to retain their state license. Provide nurses with the means to fill such requirements at minimal cost and effort with on-site classes or subsidized online class tuition reimbursement.

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www.LSBF.ca/HNDCelebrate Hard Work and Achievement Acknowledge hard work. Celebrate the achievements of nurses who do a good job. Hand out awards and gift certificates to staff members who have improved their skills, taken extra overtime when necessary and completed additional education in the field. Put up photographs of people who have been honored for other staff members to see.

Listen to Staff Concerns Keep the lines of communication open. Allow nurses to communicate directly with direct supervisors and those who run the hospital or nursing home. Encourage nurses to give feedback about what procedures work and what procedures may need to be reworked. Hold monthly meetings with all staff members. Ask nurses to speak out about their questions and concerns. Provide a fair means to allow nurses to dispute any negative feedback they may have received.

Read more: Nursing & Empowerment Concepts & Strategies | eHow.com http://www.ehow.com/list_6882033_nursing-empowerment-concepts-strategies.html#ixzz1wd14TiQn Due to the ongoing development of the nursing role, health care organizations have a duty to ensure that their workforce is providing the highest standards of care and meeting patients expectations. This

is a task that often falls to nursing managers and empowerment is an effective tool that nursing leaders can utilize in order to increase the competence and confidence of their nursing staff.

Empowerment embraces the concepts of managing with dignity and mutual respect which produces strong, efficient nurses and leaders. When considering effective nursing management, Shaw (2002) describes that empowered staff are given greater control with a move towards self direction rather than autocracy.

Autocratic management styles may lead to nurses feeling undervalued and unable to properly utilize their skills and education to benefit their patients. Conversely, a management style that focusses on trust, mutual respect, open and honest communication, and consistent support is more likely to result in a skilled and confident nursing team who are involved in decision making and who actively promote clinical effectiveness.

Scott and Caress (2005) discuss the concept of shared governance, a system of management and leadership that empowers all staff involved in patient care.

In this system, empowering staff includes involving them in decision making, facilitating motivation and job satisfaction by appraisal and job incentives, encouraging creativity, supporting education and promoting interpersonal relationships. These strategies encourage a culture of openness, honesty and responsibility.

Nurses working a positive, empowered atmosphere are more likely to maximize on opportunities to gain further education credentials, and to be motivated by the prospect of promotional possibilities. In this way, nurses become more skilled, deliver better patient care and are less likely to seek employment opportunities elsewhere.

Staff that are involved in the decision making process are more likely to feel that they are directly contributing to strategies to improve the running of their unit, higher quality patient care and cost effectiveness. Kanter (1993) considers that empowered staff are more committed to incorporating and implementing new ideas and decisions into their daily work and thus develop a sense of ownership and responsibility.

Staff may also feel more motivated to deliver their best performance once they feel that management will acknowledge their hard work either by incentive schemes, such as bonuses, or by supporting nurses by furthering their education and cross training. In this way, the empowered workplace becomes dynamic, one in which management and staff work together to achieve the highest standards of care.

Managers can create an effective work environment by empowering nurses to utilize their professional knowledge and assume accountability for their own actions. Management can motivate staff to become change agents and to develop new ideas and creative ways to improve patient care.

Management, in turn, benefits from having input from staff that are most directly involved in patient care and is able to build a more cohesive team with common goals.

This sense of motivation, shared responsibility and mutual respect may assist greatly in staff retention, allowing management to spend more time and money on improving the quality of patient care rather than on recruitment. Empowerment ultimately benefits the organization by increased productivity and work effectiveness.

This differs greatly from a hierarchical system in which nurses are simply obliged to carry out the duties assigned to them by management without really being involved in the formulation of care objectives or unit goals.

Just as the nursing process itself involves a series of interrelated and dynamic steps, implementing empowerment on nursing units can pose a great challenge and requires careful assessment, planning and implementation of change at every level of the system.

Christie Hospital NHS Trust, a hospital in Manchester, England was one of the first hospitals in the United Kingdom to implement a shared governance system based on empowering its healthcare staff in order to improve standards of care. Christie Hospital followed a series of carefully planned steps which resulted in the successful implementation of empowering nurses which showed the nursing process at management level.

Their core policy highlighted the importance of allowing staff to develop professional autonomy and encouraging staff to begin being more proactive. A steering group was formed and a vision statement

was identified that indicated that health care professionals would be involved in all decisions related to their clinical practice. They would be empowered to lead the decision making process and staff and management would work collaboratively to develop patient care standards.

The approach taken at Christie Hospital was a great success and followed the philosophy that professionals working closest with their patients are in the best position to make decisions relating to those patients. It is evident that in order to provide quality direct client care, nurses have to be given autonomy. Nursing professionals have for many years advocated for the creation of work environments that reflect the "true professional practice of registered nurses," (Ethridge, 1987, p.44.) Empowerment gives individuals the opportunity to grow in their work setting.

However, in order for management to foster an environment of empowerment, nurses must recognize the importance of accountability in the nursing profession. Nurses must have the education and ability to competently carry out their scope of practice and it is the responsibility of each nurse to make accountability a personal choice (Horsefall, 1996).

Accountability, autonomy and empowerment are closely linked. In shared governance models, the traditional controlling roles of management are replaced by a system in which management recognizes the importance of supporting nurses by ensuring that adequate resources are available to them in all aspects of their work.

Porter-OGrady (1991) adds that nurses who rely solely on management to initiate action inhibit their scope of practice considerably. Access to resources and support result in well defined nursing roles and the provision of professional client care.

In order to effectively empower staff and improve organizational outcomes, managers need to reflect on respect, justice and trust in the workplace.

A recent study by Laschinger (2005) highlighted that only 38.3% of staff nurses felt that they were respected by management. It is imperative for management to foster a trusting relationship with employees which can be achieved by adopting an open door policy and including staff in the decision making process.

Staff that are treated fairly and with respect more readily trust that management are representing their best interests. Open communication, decisional involvement and the sharing of critical information are the foundations for creating responsible, autonomous and satisfied staff and increasing retention rates. In turn, staff retention not only serves to decrease recruitment costs, but dedicated staff are more likely to be positive spokespersons for their organization, thereby attracting potential employees.

It is important to remember that the patient is the primary focus of empowered nursing and nurses who feel respected, supported and autonomous are more likely to provide higher standards of patient care.

The effort that management puts into empowering their staff will likely be rewarded by greater patient satisfaction and an improved image of the hospital as a quality care organization. Empowerment can therefore serve as a highly effective tool for hospitals seeking to gain Magnet status or to improve the quality of their overall care.

The current nursing shortage should serve as an impetus for managers to work on more effective staff retention and recruitment strategies.

Managers working on creating conditions that empower nurses foster a dynamic and independent atmosphere, where mutual trust and respect enable nurses to provide quality nursing care

Power and Empowerment in Nursing: Looking Backward to Inform the Future

Milisa Manojlovich PhD, RN, CCRN

Updated version of article and ANA online CE contact hours (CH) available.

Abstract There are compelling reasons to empower nurses. Powerless nurses are ineffective nurses. Powerless nurses are less satisfied with their jobs and more susceptible to burnout and depersonalization. This

article will begin with an examination of the concept of power; move on to a historical review of nurses power over nursing practice; describe the kinds of power over nursing care needed for nurses to make their optimum contribution; and conclude with a discussion on the current state of nursing empowerment related to nursing care. Empowerment for nurses may consist of three components: a workplace that has the requisite structures to promote empowerment; a psychological belief in ones ability to be empowered; and acknowledgement that there is power in the relationships and caring that nurses provide. A more thorough understanding of these three components may help nurses to become empowered and use their power for better patient care. Citation: Manojlovich, M. (January 31, 2007). "Power and Empowerment in Nursing: Looking Backward to Inform the Future". OJIN: The Online Journal of Issues in Nursing. Vol. 12 No. 1, Manuscript 1.

DOI: 10.3912/OJIN.Vol12No01Man01

Key words: burnout, empowerment, feminist theory, job satisfaction, nursing outcomes, nursing practice, nursing practice environment, power, relational theory, socialist feminism

The new millennium is upon us. Many advances in technology and health care indeed make this a brave new world. However, relatively little has changed in nursing, where almost 95% of all nurses are still women (Spratley, Johnson, Sochalski, Fritz, & Spencer, 2000). Even now, years after the feminist movement, many nurses do not feel empowered, and what we do "as nurses does not seem to be working" (Fletcher, 2006, p. 50). An examination of the state of the science on power and empowerment in nursing is warranted, to determine if the literature can provide insights into how, if at all, nursing can garner power for the profession as well as for patient care.

This paper will begin with an examination of the concept of power; move on to a historical review of nurses power over nursing practice; describe the kinds of power over nursing care needed for nurses to make their optimum contribution; and conclude with a discussion on the current state of nursing empowerment related to nursing care.

The Concept of Power

Power is a widely used concept in both the physical and social sciences, and as a result, there are many definitions. In the physical sciences power refers to the amount of energy transferred per unit of time.

Electricians work to provide and restore this type of power as a matter of course. Mathematicians have a different notion of power in mind when they talk about a numeral to the second (or third) power. Sociologists describe power as the ability to impose ones will upon others, and savvy researchers conduct power analyses before they begin their experiments [http://en.wikipedia.org/wiki/Power].

-------------------------------------------------------------------------------...there are compelling reasons to promote power in nursing...Nurses need power to be able to influence patients, physicians, and other health care professionals.

Several definitions of power have been used in nursing. Power has been defined as having control, influence, or domination over something or someone (Chandler, 1992). Another definition views power as "the ability to get things done, to mobilize resources, to get and use whatever it is that a person needs for the goals he or she is attempting to meet" (Kanter, 1993, p. 166). For Benner, power includes caring practices by nurses which are used to empower patients (Benner, 2001). Power may also be viewed as a positive, infinite force that helps to establish the possibility that people can free themselves from oppression (Ryles, 1999).

Some researchers have described types of power, such as legal, coercive, remunerative, normative, and expert power (Conger & Kanungo, 1988). Of particular interest to nursing is the concept of expert power, which has been defined as "the ability to influence others through the possession of knowledge or skills that are useful to others" (Kubsch, 1996, p. 198). Benner (2001) has described qualities of power associated with caring provided by nurses such as transformative and healing power. Transformative and healing power contribute to the power of caring, which is central to the profession of nursing (Benner, 2001).

Power is necessary to be able to influence an individual or group. Nurses need power to be able to influence patients, physicians, and other health care professionals, as well as each other. Powerless nurses are ineffective nurses, and the consequences of nurses lack of power has only recently come to light (Page, 2004). Powerless nurses are less satisfied with their jobs (Manojlovich & Laschinger, 2002), and more susceptible to burnout and depersonalization (Leiter & Laschinger, 2006). Lack of nursing power may also contribute to poorer patient outcomes (Manojlovich & DeCicco, in review). Studies such as these suggest that there are compelling reasons to promote power in nursing.

Historical Review of Nurses Power over Nursing Practice

-------------------------------------------------------------------------------Although the feminist movement of the 1960s did much to bring women in other professions on an equal footing with men, nursing's low status in the health care hierarchy remains.

A historical review of nurses power over nursing practice should include social, cultural, and educational factors that influence nurses power over their practice. Social and cultural factors that influence nursing power have their roots in the view of nursing as womens work (Wuest, 1994). Initially, nursing was a domestic role women were expected to fulfill in the home (Wuest). In addition, a lot of nursing work is done in private, behind drawn curtains (Wolf, 1989). The persistent invisibility of a lot of nursing work decreases nursings social status and perceived value (Benner, 2001; Wolf), contributing to powerlessness.

The fact that womens right to vote is less than 100 years old suggests oppression of women was common in the not too distant past, and may explain in part ongoing powerlessness. Although the feminist movement of the 1960s did much to bring women in other professions on an equal footing with men, nursings low status in the health care hierarchy remains. Educational factors contribute to this situation, and they are twofold. First, nursing has historically been taught in hospitals, perpetuating nursings low status in relation to physicians and other health care providers. Since twenty-two percent of nurses in America today are diploma graduates (Spratley et al., 2000), this educational factor may still be contributing to nursings powerlessness. Second, the multiple entry levels into nursing practice further dissipate whatever influence nursing may be able to generate. Nursings ongoing debate over entry level issues may be contributing, inadvertently, to the lack of power that education should be mitigating.

-------------------------------------------------------------------------------Nursing's ongoing debate over entry level issues may be contributing, inadvertently, to the lack of power that education should be mitigating.

It has been over twenty years since both Styles and Hall maintained that power is central to nursings development as a profession (Hall, 1982; Styles, 1982). Nurses lack of power may be rooted in a societal reluctance in general to discuss power openly (Kanter, 1979). Nurses may be more reluctant than most to discuss power because 95% of all nurses are women (Spratley et al., 2000), and women have not been socialized to exert power (Rafael, 1996). Historically nurses have had difficulty acknowledging their own power (Rafael). This reluctance to acknowledge and subsequently use ones power as a nurse may in part explain many nurses inability to control their practice.

According to Rafael (1996) power has been viewed as a outcome of masculinity and in direct opposition to caring, which is seen as the essence of nursing and traditionally aligned with femininity. Many nurses may be reluctant to access or use power because they view power as a masculine attribute that is inconsistent with their self-identities as women. Therefore, a masculine view of power may be contributing to nurses continuing lack of power.

Kanter (1993) maintains that power is acquired through the process of empowerment. She views empowerment as arising from social structures in the workplace that enable employees to be satisfied and more effective on the job (Kanter, 1993). Chandler argues that empowerment arises from relationships and not merely from the parceling out control, authority, and influence (Chandler, 1992). Empowerment has been conceptualized from many different perspectives (Kuokkanen & Katajisto, 2003). Empowerment may be either an individual or a group attribute (Ryles, 1999). It may arise from the work environment (Kanter, 1993) or from within ones own psyche (Conger & Kanungo, 1988) and may be viewed as either a process or an outcome (Gibson, 1991).

The concept of empowerment emerged in the late 1960s and early 1970s as a result of the self-help and political awareness movements (Ryles, 1999). Although power has been discussed in nursing literature since the 1970s (Kalisch, 1978), Chandler (1986) was among the first to describe the process of empowerment in nursing. Chandler (1992) also distinguished between power and empowerment, noting that empowerment enables one to act, whereas power connotes having control, influence, or domination.

Ongoing research on empowerment in nursing has demonstrated that empowered nurses are "highly motivated and are able to motivate and empower others by sharing the sources of power" (Laschinger & Havens, 1996, p. 28). Empowered nurses experience less burnout (Laschinger, Finegan, Shamian, & Wilk,

2003) and less job strain (Laschinger, Finegan, & Shamian, 2001). Alternatively, disempowerment, or the inability to act, creates feelings of frustration and failure in staff nurses, even though they may still be accountable (Laschinger & Havens, 1996).

Historically access to and the content of nursing education has not been fully under the control of nurses (Rafael, 1996). Other groups continue to exert control over nurses professional lives, as exemplified by the increasing use of unlicensed health care personnel and the medical lobby opposing nurse practitioners as primary health care providers (Rafael). It is small wonder that nursing remains powerless relative to other professions.

Despite empirical evidence of the positive outcomes of empowerment for nursing practice, a historical perspective is helpful in understanding why many nurses remain disempowered. As long as nurses view power as only having control or dominance, and as long as nursing does not control its own destiny, nurses will continue to struggle with issues of power and empowerment.

Kinds of Power over Nursing Care Needed for Nurses to Make Their Optimum Contribution

There are at least three types of power that nurses need to be able to make their optimum contribution. The various types of power can all be categorized as stemming from nurses control in three domains: control over the content of practice, control over the context of practice, and control over competence. The continued lack of control over both the content and context of nursing work suggests that power remains an elusive attribute for many nurses (Manojlovich, 2005a). In this section, power will be discussed as it is manifested by nurses control over the content, context, and competence of nursing practice.

Control Over the Content of Nursing Practice

Power is an attribute that nurses must cultivate in order to practice more autonomously because it is through power that members of an occupation are able to raise their status, define their area of expertise, and achieve and maintain autonomy and influence (Hall, 1982). One of the characteristics of a profession is that professionals have power over the practice of their discipline which is often referred to as professional autonomy (Laschinger, Sabiston, & Kutszcher, 1997). Autonomy represents one kind of power nurses need, and has been defined as "the freedom to act on what one knows" (Kramer & Schmalenberg, 1993, p. 62). Therefore a key element of empowerment is nurses control over their

practice (Page, 2004). The ability to act according to ones knowledge and judgment is known as control over the content of nursing practice (Laschinger et al., 1997), and is often synonymous with autonomy. High levels of autonomy increased nurses identification with the profession in one study (Apker, Ford, & Fox, 2003), providing recent empirical support for this supposition.

-------------------------------------------------------------------------------Having control over the content of nursing practice may not be enough to provide power for nurses.

Of all decision makers in the hospital environment, only the bedside nurse, who is in closest proximity to the patient, can fully appreciate subtle patient cues and trends as they arise and act on them to properly care for that patient (Manojlovich, 2005a). To identify the appropriate course of action and effectively function, professionals must have understanding and control over the entire spectrum of activities associated with the job at hand (Manojlovich). However, it may be that nurses are frequently unable to use their professional preparation, which focuses on autonomous practice and independent decision making, because they are powerless relative to organizational administrators and medical staff (Manojlovich). Having control over the content of nursing practice may not be enough to provide power for nurses.

Control Over the Context of Nursing Practice

Besides control over the content of nursing practice, which represents one type of power, a related type of control is known as control over the context of practice, and represents another type of power that nurses need (Laschinger et al., 1997). Over twenty years ago it was noted that "nurses should be more meaningfully involved in the running of hospitals" (Prescott & Dennis, 1985, p. 348). Nurses involvement in hospital affairs is one of the hallmarks of a magnet hospital environment (McClure & Hinshaw, 2002) but otherwise may not be apparent.

Research on magnet hospital characteristics has largely demonstrated relationships between the work environment and patient outcomes (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Aiken, Sloane, Lake, Sochalski, & Weber, 1999). The positive findings of the magnet hospital research may be attributed to empowering organizational social structures, although they were not identified as such. Hospital

characteristics which were found to attract and retain qualified staff nurses included decentralization and participatory decision making. Although relatively little attention has been paid to how a magnet work environment contributes to nurses sense of power (Upenieks, 2003c), repeated magnet hospital study findings of empowering workplace structures and their relationship to improved nursing and patient outcomes suggest that magnet hospitals attract nurses in part because of their empowering environments.

-------------------------------------------------------------------------------All of the magnet hospital studies have also consistently demonstrated positive benefits for nursing and patients when nurses control both the content and the context of their practice.

All of the magnet hospital studies have also consistently demonstrated positive benefits for nursing and patients when nurses control both the content and the context of their practice. In the original magnet hospital study, nursing staff felt able to influence decisions and were in control of their own practice, while recognizing the power of physicians and nurse leaders (McClure, Poulin, Sovie, & Wandelt, 1983). The original magnet hospital study also recognized that the power base of staff nurses emerged from nursing leadership, whose power came from staff, hospital administrators, and boards of trustees (McClure et al.). A more recent study has validated the magnet hospital findings, demonstrating that strong nursing leadership strengthens the effect of empowerment on nursing practice behaviors (Manojlovich, 2005c). Professional practice models, shared governance models, and collaborative governance all use similar processes to increase nurses participation in decision making, thereby increasing their control over the context of nursing practice and promoting power.

There is strong empirical justification for promoting nurses power through control over both the content and context of nursing practice. In multiple studies, patient outcomes were improved when the hospital organization was supportive of autonomous nursing practice (Aiken et al., 1999; Aiken, Clarke, & Sloane, 2000). In these studies, autonomous nursing practice was operationalized as control over the practice environment, decision-making ability, and collegial relationships with physicians, suggesting an important link between power and patient outcomes.

Control Over the Competence of Nursing Practice

A necessary precursor for both autonomy and power is competence (Kramer & Schmalenberg, 1993), which has its foundation in educational preparation. Power is maintained through knowledge development (Rafael, 1996), which is acquired through education and expertise. The multiple entry levels into nursing practice, as well as the low educational level of nurses (relative to other health care professionals) may contribute to nurses powerlessness. The statement, "Being less well-educated than other groups within the hospital puts nursing at a serious disadvantage in organizational politics" (Prescott & Dennis, 1985, p. 355), is no less true now than it was when written more than twenty years ago.

Nursing expertise is a related source of power that has a transformative effect on patients lives ((Rafael, 1996). Expertise is not the same as experience, nor can expertise be acquired on nursing units with high turnover (Benner, 2001). This suggests a complex relationship between organizational factors that contribute to nursing turnover and the development of nursing expertise. Educational preparation and expertise represent two additional types of power nurses need to make their optimal contribution to patient care.

Organizational systems aimed at promoting nurses power so that they can use their professional skills may provide an attractive and rewarding career choice for todays sophisticated students (Bednash, 2000). There may be additional benefits for hospitals that promote nursing power. Bednash (2000) reported on a study indicating that hospitals that allowed their staff autonomy over their own practice and active participation in decision making about patient care issues were the most successful in recruiting and retaining nurses. In another study patient satisfaction improved when there was more organizational control by staff nurses (Aiken et al., 1999).

The Current State of Nursing Empowerment Related to Nursing Care

Part of the difficulty many nurses have in being powerful may be due to their inability to develop the types of power described in the previous section. Power over the content, context, and competence of nursing practice contributes to feelings of empowerment, but control in these three domains may not be enough. An examination of the two major areas of empowerment literature in nursing, as well as a third area not yet embraced by nursing, may help inform future directions for the development of power and empowerment for nurses.

Empowerment in nursing has largely been studied from two perspectives. Most nursing researchers view empowerment as either arising from the environment (Laschinger, Finegan, Shamian, & Wilk, 2001) or developing from ones psychological state (Manojlovich, 2005b; Spreitzer, 1995).

Another contributor to nurses lack of power may be that they dont understand how power can develop from relationships, as originally proposed by Chandler (1992). Therefore a third perspective on empowerment, not yet embraced by nursing, is gender specific. Relational theory explains how women engage in relationships to foster growth and nurturance (Fletcher, Jordan, & Miller, 2000). Women develop empathy and empowerment through relationships, although the mutual processes of empathy and empowerment are largely invisible (Fletcher et al., 2000).The answer to increasing nursing empowerment may lie in understanding workplace sources of power, expanding the view of empowerment to include the notion of empowerment as a motivational construct, and finally making more explicit growth fostering relationships which also contribute to power.

Theory of Structural Empowerment

The theory of structural empowerment states that opportunity and power in organizations are essential to empowerment, and must be available to all employees for maximal organizational effectiveness and success. The theory of structural empowerment was developed by Kanter (1993) who saw employees work behavior as arising from conditions and situations in the work place, and not from personal attributes (Laschinger & Havens, 1996).

There are four structural conditions identified by Kanter (1993) as being the key contributors to empowerment. They are: having opportunity for advancement or opportunity to be involved in activities beyond ones job description; access to information about all facets of the organization; access to support for ones job responsibilities and decision making; and access to resources as needed by the employee (Kanter, 1993). Empowerment is on a continuum, because the environment will provide relatively more or less empowerment, depending on how many of the four structures are present in the work setting. The theory of structural empowerment places the focus of causative factors of behavior fully on the organization, in effect maintaining that powerless individuals have not been exposed enough to the four empowering workplace structures.

In this worldview of empowerment, employees behavior is merely a response to the structural conditions they face in the work setting. Therefore, the qualities of a job and its context evoke behaviors from those in a job position that determine the likelihood of success (Kanter, 1993). Employees

behavior becomes more effective, and organizational output increases and improves when the organization is structured to provide opportunity and power to all employees across all organizational levels (Kanter, 1993).

Laschinger and her colleagues have done the bulk of the work on structural empowerment in nursing (Laschinger, Finegan, Shamian, & Almost, 2001; Laschinger et al., 2003; Laschinger, Finegan, Shamian, & Wilk, 2004; Leiter & Laschinger, 2006; Sabiston & Laschinger, 1995). However evidence of the essence of structural empowerment, if not the name, appears in other research as well. Kramer and Schmalenberg (1993) identified organizational strategies necessary before individuals could act in an empowered manner. These included participative management, job enrichment, meaningful organizational goals, less bureaucracy, and involving staff in decision making (Kramer & Schmalenberg, 1993). Although not identified as conditions in the environment, the access to opportunity, resources and support that these strategies would provide would certainly strengthen nurses perceptions of empowerment.

Other than the magnet program there is additional support for configuring work environments in a way that promotes empowerment. Aiken and colleagues (2001) conducted an international study in five countries to compare nurse staffing, work environments, and patient outcomes. Even in countries with vastly different health care systems nurses reported similarities in workplace empowerment elements. The results of this international study further suggest that the relative presence or absence of specific environmental factors associated with structural empowerment may contribute to variation in nursing and patient outcomes in multiple countries.

There is evidence in the literature that structural empowerment contributes to higher levels of job satisfaction (Manojlovich, 2005d), and is interrelated with nursing leadership (Upenieks, 2003a). In fact, nursing leaders must empower themselves by first accessing empowering work environment structures before moving forward to offer these same empowering work conditions to their staff (Upenieks, 2003b).

Theory of Psychological Empowerment

Thus empowerment, as provided by the environment, tells part of the story, but alone it is not enough. Some environments are empowering because they allow workers to do what it is the workers feel is necessary to get the job done. In other words, these environments provide the sources of power. Other work environments may not be as empowering, yet there will still be a few hardy individuals who manage to do whatever it takes to be effective on the job. It may be that these people are able to

recognize what few empowering social structures in the environment are present, and manipulate them, since it is only in recognition that the structures can be used.

An alternative theoretical perspective on empowerment acknowledges the fact that empowerment is also a psychological experience. Conger and Kanungo (1988) viewed empowerment as a motivational construct, while maintaining that it is still a personal attribute. They saw empowerment as enabling, which "implies motivating through enhancing personal efficacy" (Conger & Kanungo, 1988, p. 473). Spreitzer (1995) developed this version of empowerment further. According to Spreitzer, the process of psychological empowerment is a motivational construct which manifests as a set of four cognitions that are shaped by a work environment. The four cognitions are: meaning, competence, self-determination, and impact (Spreitzer, 1995).

Meaning occurs when there is congruence between a nurses beliefs, values, and behaviors, and job requirements (Laschinger, Finegan, & Shamian, 2001). Competence refers to confidence in ones abilities to perform the job, and is also known as self-efficacy (Laschinger, Finegan, & Shamian). Selfdetermination, similar to autonomy, refers to feelings of control that are exerted over ones work. Finally, impact is seen as a sense of being able to influence important organizational outcomes (Laschinger, Finegan, & Shamian).

Psychological empowerment is a process because it begins with the interaction of a work environment with ones personality characteristics; then the interaction of environment with personality shapes the four empowerment cognitions, which in turn motivate individual behavior (Spreitzer, 1995). Psychological empowerment reflects an active rather than a passive orientation to work, and conveys the notion that individuals not only want to, but are able to, shape their work role and context (Boudrias, Gaudreau, & Laschinger, 2004).

Several studies have demonstrated the effect of psychological empowerment on nursing outcomes of burnout and nursing job satisfaction (Laschinger, Finegan, & Shamian, 2001; Laschinger, Finegan, & Shamian & Almost, 2001). Self-efficacy for nursing practice (one of the psychological empowerment cognitions) was recently found to contribute to professional nursing practice behaviors (Manojlovich, 2005b). In fact, this study demonstrated that structural empowerment contributed to professional practice behaviors through self efficacy, consistent with the notion that both forms of empowerment may be necessary to sustain professional practice behaviors (Manojlovich). Research has also shown that work environment characteristics, such as structural empowerment, contribute to psychological empowerment in both nursing (Laschinger, Finegan, & Shamian & Almost, 2001) and non-nursing populations (Spreitzer, 1996).

A Relational View of Empowerment

-------------------------------------------------------------------------------Relational theory may have greater relevance to the development of empowerment in nursing than either workplace or motivational views of empowerment because of the nature of nursing's work.

Despite the large amount of literature describing how to foster empowerment, a recent study done in New York reported that nurses are feeling they still lack power to influence their working conditions (Brewer, Zayas, Kahn, & Sienkiewicz, 2006). In addition to accessing workplace structures to garner structural empowerment, and developing power through psychological empowerment, yet one more perspective on empowerment may be required.

Viewing empowerment through a feminist lens may help explain persistent findings of disempowerment. Most feminist scholarship on nursing focuses on overcoming oppressive working conditions brought on by the patriarchal structure of medicine and the health care industry (Chinn, 1995; Sampselle, 1990). Feminist theory that focuses on eliminating oppression and seeking equal status for women is known as liberal feminism (Wuest, 1994). While this perspective has its merits, it tends to dichotomize the empowerment debate and becomes constraining when viewed as part of a dualistic ideology: masculinity/femininity; oppressor/oppressed; good/bad; right or wrong.

An alternative feminist perspective argues for a relational context to empowerment: one that values and rewards interactive relationships (Chandler, 1992; Rafael, 1996).

-------------------------------------------------------------------------------...a truly empowering environment for nurses should nurture reciprocal professional relationships.

This perspective falls under the broad umbrella of socialist feminist theory, and emphasizes the development of relationships through interactions with one another (Wuest, 1994). Socialist feminists maintain that the worldview of women is valid not because women are equal to men, but because womens reality provides knowledge inaccessible to men (Wuest, 1994).

Relational theory comes from the school of social feminism, and posits that women engage in growth fostering and nurturance relationships, which maintain society (Fletcher et al., 2000). Women foster growth and nurture others, deriving strength from the relationships and bonds that develop as a result of these activities (Fletcher et al.). By engaging in growth fostering relationships at work, mutual empowerment ensues and enables the achievement of others and increases ones own job effectiveness (Fletcher et al.). Relational theory may have greater relevance to the development of empowerment in nursing than either workplace or motivational views of empowerment because of the nature of nursing work. As Chandler has argued:

Clinical knowledge and committee work is only one piece of the staff nurse-based formula for empowerment. The other critical variables are those underestimated, trivialized, and unexamined aspects of what has been womens domainthe domain that nurses know and would prefer (Chandler, 1992, p.70).

Thus Chandler implies that a psychological belief in ones ability to be empowered may not be enough to increase empowerment in nursing, but that a truly empowering environment for nurses should nurture reciprocal professional relationships.

Fletcher (2006) suggests a relational theory approach when she asserts that nurses need to focus on relationships to build power. Fletcher maintains that relationships are built through dialogue and selfawareness and that the development of self-awareness "can begin to break the cycle of oppression and lead to changes in the structures that oppress nurses" (Fletcher, 2006, p. 57). Benner (2001) also argues for power through relationships and caring: the core of nursing practice. When nursing embraces caring, empathy, and compassion as components of power, nurses will be more likely to adopt and accept power as part of their practice (Benner).

Conclusion

-------------------------------------------------------------------------------...there remains a need for research to examine the power that exists in relationships.

In conclusion, nurses power may arise from three components: a workplace that has the requisite structures that promote empowerment; a psychological belief in ones ability to be empowered; and acknowledgement that there is power in the relationships and caring that nurses provide. Nursing research has been able to demonstrate the relationship between the first two components and empowerment; yet there remains a need for research to examine the power that exists in relationships. Nursing research from a relational theory perspective may help make nurses power more explicit and more visible, moving our understanding of power in nursing further than has previously been possible. A more thorough understanding of these three components may help nurses to become empowered and use their power for their practice and for better patient care.

Author Milisa Manojlovich PhD, RN, CCRN E-mail: mmanojlo@umich.edu

Dr. Manojlovich graduated from an ADN program in 1985, and received CCRN certification in 1989. She maintains her CCRN status by practicing as a staff nurse in the Medical Intensive Care Unit at the University of Michigan Health System two days a month. She received her PhD in 2003, and is currently an Assistant Professor at the University of Michigan. Dr. Manojlovich has been fascinated by the hospital environments effect on nursing practice ever since becoming a nurse, and is developing a research program investigating how empowerment can improve both nursing and patient outcomes. Dr. Manojlovich has written numerous publications describing the relationship of empowerment to nursing variables and works closely with Dr. Heather Laschinger, one of the foremost experts on nursing empowerment.