Nurse Empowerment, Self-Efficacy, and Patient Safety

Introduction

Patient safety, as defined by the National Patient Safety Foundation, is “the avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of health care” (National Patient Safety Foundation, 2016, para. 12). Patient safety is an expected characteristic of hospital stays. Although patients, their families, and health care providers expect hospital care to be safe, medical errors in U.S. hospitals result in more than 400,000 patient deaths annually (James, 2013). Nurses are well positioned to assess changes in patient conditions and prevent treatment errors (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002). Nursing professionals’ vigilance at the bedside is essential to safeguard patient care and to detect medical errors such as incorrect medication orders (Aiken et al., 2002). For bedside nurses to provide safe patient care, nurse executives must actively and continuously promote a culture of patient safety. Such a culture ensures that bedside nurses are empowered to perform their roles and are given the resources necessary to fulfill their responsibilities in a safe manner (Aiken et al., 2002).

Empowerment

Alsop and Heinsohn (2005) have described empowerment as the development of an individual or a group’s ability to actualize choices. This definition has two components: a process through which individuals become empowered and an outcome in which individuals have acquired an ability to actualize choices as desired actions or outcomes (Alsop & Heinsohn, 2005, p. 5). In hospitals, empowerment is closely linked to safe patient care. In the delivery of such care, empowerment plays a pivotal role in creating a practice environment that is productive and healthy for both patients and care providers (Greco, Laschinger, & Wong, 2006). In acute care hospitals, a conducive environment for empowerment can facilitate the delivery of safe patient care and decrease the breakdowns in safety that currently exist in health care, as evidenced by the alarming number of medical errors in the United States. Greco et al. (2006) revealed a strong correlation between empowerment of nursing professionals and the level of their burnout (as well as job fit) that was regarded as one of the primary factors contributing to the increase in errors in the clinical setting. Richardson and Storr (2010) implemented a review of studies that also showed the link between empowerment and medical errors. The studies mentioned proved that the number of medical errors was smaller when nursing professionals were able to make decisions concerning some aspects of patients’ treatment (for example, injections).

The Nurse Executive Role

In acute care hospitals, nurse executives such as chief nursing officers and nurse directors provide leadership by coordinating the operational components that are essential for patient safety: a culture of safety; adequate planning for care and services; resources (human, monetary, physical, and informational); staffing and resources to assure staff competency; and a commitment to performance improvement (Schyve, 2009). The diverse responsibilities of nurse executives also include strategic leadership for all nursing and other designated patient care functions and services, fiscal management of patient care, and compliance with objectives and strategies for the provision of safe, high-quality care (Englebright & Perlin, 2008; Frederickson & Nickitas, 2011; Havens, Thompson, & Jones, 2008).

Empowerment of Nurse Executives

Because both nurse executives’ responsibilities and health care itself are so complex, nurse executives must be empowered to perform their leadership roles (Mathena, 2002). Empowerment enables nurse executives to facilitate the delivery of safe patient care by their professional actions (e.g., rounding on direct reports and providing equipment needed for patient care) and their personal behavior (e.g., respectful communication that welcomes staff concerns) to influence co-workers such as bedside nurses. By virtue of their position in hospital organizations, nurse executives can create a work environment that is conducive to nurse empowerment and patient safety. To create such an environment, nurse executives themselves must feel empowered (Greco et al., 2006).

Purpose of Integrative Review

In this integrative review, I will (a) discuss current knowledge and gaps in knowledge on the empowerment of nurse executives, (b) clarify how empowerment of nurse executives and staff nurses relates to self-efficacy and patient safety, and (c) propose how this research can enrich knowledge in the field of patient safety.

Background and Significance

How the presence or absence of nurse executive empowerment influences the delivery of patient care is the core issue. In becoming empowered, nurse executives must develop administrative judgment, sensitivity, and self-confidence, cognitive and affective abilities that are critical for leaders in acute care hospitals (Greco et al., 2006). Through empowerment, nurse executives can structure work environments that enable their nurses to deliver high-quality patient care, achieve high patient satisfaction scores, and produce positive patient outcomes (Mathena, 2002). In acute care settings, the responsibilities of nurse executives are extensive and consequential (Greco et al., 2006; Platt & Foster, 2008).

Nurse executives are pivotal in directly or indirectly creating organizational goals and expectations that influence patient safety. To achieve such goals, they must foster hospital relationships in ways that build and maintain trust while inspiring the commitment of others to achieve organizational goals (Englebright & Perlin, 2008; Frederickson & Nickitas, 2011; Havens, Thompson, & Jones, 2008). Trust among hospital staff is a key element of a patient safety culture and maintenance of the proper working environment (Hughes, 2008). Healthcare professionals can collaborate effectively as trust facilitates honest and open communication that encourages nurses to notice safety flaws, real or potential, and take corrective or preventive action. Auer, Schwendimann, Koch, Geest, and Ausserhofer (2014) found that nurses’ trust in hospital management contributed to the improvement of patient safety as nurses trusting their leaders could openly share their experiences, discuss errors made and ways to prevent and address them. The researchers stressed that open communication was one of the outcomes and, at the same time, the ground for the development of trusting relationships among healthcare professionals. The open discussion facilitated learning that translated into the development of effective methods and strategies associated with corrective measures.

In executing their responsibilities, nurse leaders must model behaviors and set expectations that empower nursing professionals to support patient safety (Schyve, 2009). Such actions include partnering with physicians to develop patient placement criteria that ensure assignment to the right level of care. When nurse leaders model behaviors like respectful communication, they demonstrate professionalism that can empower bedside nurses to voice concerns about patient safety without fear of humiliation or retribution (Schyve, 2009). Finally, when nurse executives champion patient safety as their hospital’s priority, they promote a culture of safety and a safe working environment. My dissertation will explore the relationship between the empowerment of nurse executives and an environment that facilitates the delivery of safe, quality patient care.

Theoretical Approach

Researchers have used a number of theoretical frameworks to address such issues as patient safety and nurses’ empowerment. Normal accident theory (NAT) and high reliability theory (HRT) enable health care professionals to understand patient safety and develop highly reliable organizations (HROs; Cooke, 2009). According to Perrow (1999), organizations (be it a nuclear power plant, laboratory or hospital) are complex systems consisting of various components that may interact in different ways. These interactions tend to result in emergency situations, which makes accidents “inevitable, even normal” (Perrow, 1999, p. 4). It is often difficult to prevent the occurrence of accidents as the characteristics of the components and especially the ways they can interact are often insufficiently researched due to the substantial number of components and variations of their interaction. The clinical environment can be regarded as one of these complex systems highly vulnerable to accidents. Each of the accidents can result in negative health outcomes for patients.

In the clinical setting, the NAT has been widely applied while some researchers regard it as a pessimistic paradigm. For instance, Haavik, Antonsen, Rosness, and Hale (2016) claim that the theory focuses on sociotechnical aspects and implies low chances of addressing risks effectively. Nevertheless, the theory is instrumental in managing high-risk accidents as it unveils characteristics of the systems that are at risk. Perrow (1999) argues that such measures as duplication, decentralization and continuous learning (and training) can help organizations prevent numerous accidents and mitigate the outcomes of emergencies that have taken place. Schwappach, Pfeiffer, and Taxis (2016) used this theoretical approach to address patient safety issues in clinical practice and found that duplication (double-checking) was seen positively by nursing professionals who believed that the practice contributed to the decrease in medical errors.

The high reliability theory was created as a response to the rather pessimistic NAT. Cooke (2009) states that some organizations have successfully managed risk and they can be referred to as high reliability organizations. HROs continuously improve performance by creating system solutions quickly to resolve organizational problems (Cooke, 2009). The primary features typical of HROs include the placement of safety at the center, which presupposes a lot of training and ongoing learning. Another feature of the HRO is the development of informal networks and flexibility. Finally, HROs “build in ‘redundancies’ that can back up failures of individual components” that can result in the prevention of systemic errors (Cooke, 2009, p. 260). In simple terms, in HROs, people focus on safety, train and learn from their past experiences to prevent and manage high-risk accidents. At the same time, the high reliability theory is associated with a number of flaws as it underestimates such external factors as political influences and fails to pay the necessary attention to the underlying reasons for accidents (Cooke, 2009). Another weakness of this theoretical paradigm is that it implies an easy change in the organizational culture from the top. Therefore, researchers note that practitioners should mind these peculiarities (strengths and weaknesses) when applying the HRT or NAT (Cooke, 2009).

It has been acknowledged that culture of patient safety that is informed by the NAT and HRT leads to positive patient outcomes such as (a) decreased mortality rates; (b) decreased hospital-acquired pneumonias, infection, and pressure ulcers, (c) decreased rates of failure to rescue, (d) minimal opportunities for medical errors to occur, and (e) increased patient satisfaction (Feng, Bobay, & Weiss, 2008). Health care organizations that promote patient safety must begin with nurse executives who promote a culture of patient safety.

Two theories, Kanter’s (1977) theory of organizational empowerment and Bandura’s (1977) theory of self-efficacy, offer a theoretical basis for understanding empowerment. The aim of this study is to examine the correlation between empowerment, self-efficacy, and patient safety. Therefore, it is critical to pay the necessary attention to theoretical paradigms used by researchers exploring self-efficacy and empowerment with the focus on the clinical setting. Kanter’s theory discusses the structural determinants of empowerment. Bandura’s theory is often applied when researchers and practitioners try to understand, develop, and optimize nurse executive behaviors that promote empowerment.

Empowerment to improve patient safety requires that staff nurses excel in their role and responsibilities (e.g., advancing from bedside to supervisory roles, presenting in-service programs to colleagues, and exhibiting autonomy in direct patient care) and have the knowledge to perform tasks, the information to complete jobs, and access to required resources (Kanter, 1977). In addition, the empowerment of nurse managers (midlevel management) requires the support of their superiors (i.e., nurse executives) to facilitate the achievements of frontline nurses as well as their own achievements (e.g., role autonomy, authority to order equipment for patient care, opportunities for promotion, and opportunities to promote their staff). These factors not only strengthen employee engagement in their work but also promote job satisfaction. Kanter’s (1977) concepts of organizational empowerment, which were derived from actual organizations, are applicable to health care organizations.

Bandura’s (1977) theory of self-efficacy can elucidate the dynamics that influence human behavior. In this theory, self-efficacy is defined as one’s belief in one’s own capability to succeed in such courses of action needed to attain or influence an outcome (Bandura, 1977). Fundamentally, people have the ability to influence their own actions and outcomes (Smith & Liehr, 2008). For self-efficacy to develop, one must be capable of assessing one’s behavior and beliefs about what one can accomplish (Smith & Liehr, 2008). Beliefs about self-efficacy, according to Bandura (1997), “constitute the key factors of human agency” (p. 3). High self-efficacy has a positive effect on behavior (Smith & Liehr, 2008). Conversely, an individual’s belief that she or he cannot change outcomes will reduce the likelihood that they will engage in or persevere in behaviors to produce results. The achievement of positive patient outcomes requires that frontline nurses believe in their care assessments and abilities. Leaders too must believe in themselves and their ability to influence frontline nurses to deliver safe patient care.

Organizational theorists have identified several leadership practices that increase self-efficacy (Conger & Kanungo, 1988). Leaders who express confidence in nurses and provide them with opportunities to make or take part in practice decisions create an empowering environment. To create an organization whose policies and practices are empowering, nurses must be knowledgeable of their own self-efficacy (Congor & Kanungo, 1988). Conceptually, nurse executive leaders must believe not only that they can effect change but also that they are able to do so.

Self-efficacy applies to other behaviors that can promote patient safety. Acute care environments in which nurses are encouraged, respected, and praised for voicing safety concerns, without fear of retribution, is conducive to open, honest communication. Such communication fosters greater involvement in decisions about patient care and the environment in which they provide care (Havens & Aiken, 1999).

Kanter (1977) and Bandura’s (1977) conceptual frameworks guided this integrative review, elucidating the concepts of empowerment and self-efficacy as they pertain to patient safety in acute care settings. Using these frameworks, I identified literature that discusses the concepts (i.e., empowerment in organizational settings, engagement in work environments, behaviors that promote one’s ability to deliver safe patient care, and a culture of patient safety) and relevant terms (i.e., nurse leader, empowerment, nurse self-efficacy, patient safety) that are key to understanding the phenomenon of empowerment at the nurse executive level.

Integrative Literature Review

In the light of nurse executives’ central role in acute care hospital operations and the importance of institutional empowerment, a clear understanding of nurse executive empowerment will better explain the relationship between empowerment in the clinical environment, patient safety, and the delivery of quality care. To date, nurse executive empowerment has not been thoroughly studied. The purpose of this integrative literature review is to analyze studies of the effect of empowerment on patient safety.

Aims of the Review

The aims of this integrative review were (a) to analyze how the concept of empowerment has been used in nursing research and theory, (b) to discuss research on how empowerment of nurse leaders and frontline nurses has affected patient safety, and (c) to discuss research that demonstrates the relationship of nurse self-efficacy to patient safety. This analysis will present current knowledge on these topics and reveal gaps in knowledge that I will address in my dissertation.

Methods

An integrative review of health-related literature was conducted using Whittemore and Knafl’s (2005) five-step process: problem identification, literature search, data evaluation, data analysis, and presentation.

Problem identification

An excessive number of errors occur in hospital settings every year. Facilitating the empowerment of nurse executives and other nurses has the potential to decrease those errors and facilitate safety. This review aims at examining the most relevant findings, as well as methodologies and theoretical paradigms used to implement research, associated with the correlation between patient safety and nurses’ empowerment.

Literature search

The focus of this search was nurse executive empowerment, patient safety, and nurse self-efficacy in health care settings. A search of the CINAHL, PSYCHInfo, and PubMed databases using MeSH terms yielded 1,665 articles of interest. Iterative searches using a combination of other MeSH terms reduced the number of relevant articles to 252 (see Appendix A).

Data evaluation

Data from theoretical and empirical literature were reviewed (Whittemore & Knaff, 2005). A wide variety of research methods (e.g., mixed methods, survey questionnaire, and longitudinal design) were selected, and the articles to be reviewed were organized in table format for further analysis.

Data analysis

The research articles on nurse empowerment, patient safety, and self-efficacy were grouped by theme to allow for easier categorization and analysis (Whittemore & Knaff, 2005).

Presentation

Table 2 presents the findings of this review. The sample size, design and instrumentation, theoretical framework, major findings, generalizability, and strengths and limitations for each research article are found in Appendix B.

Quality Appraisal

This literature review relied on the guidelines for research evaluation developed by Pluye, Gagnon, Griffiths, and Johnson-Lafluer (2009) and Pluye et al. (2011). The criteria for quantitative studies included institutional review board (IRB) approval, a description of variables and methods, and logical data collection and analysis (Pluye et al., 2011). In addition, the appropriateness of measurement tools (i.e., clear origin, known validity, or a reliable standard instrument), sampling strategy, and sample under study were evaluated (Pluye et al., 2011).

The criteria for qualitative studies included IRB approval, participant informed consent, credibility, context, and reflexivity. Credibility means the appropriate selection of participants that allows for a thorough, relevant collection of data (Pluye, et al., 2011). Context refers to setting and how settings influence data collection (Pluye, et al., 2011). For example, does a for-profit hospital influence nurse executive empowerment differently than a nonprofit hospital? Context must be addressed as data is gathered. Reflexivity, at a minimum, must be discussed, and disclosure of “what brought them [researchers] to the question” must be provided (Pluye, et al., 2011, p. 3). Qualitative guidelines also encompass the process of data analysis and the setting in which data was gathered (Pluye et al., 2011).

Strategy for Literature Search

The strategy for this integrative review involved an initial search on patient safety, nurse leadership, empowerment, and self-efficacy. Subsequent searches were conducted on empowerment, patient safety, and nurse self-efficacy. Appendix A provides a summary of the literature search, including databases used, search terms applied, and results found.

The search also involved a manual review of reference lists in the articles selected for review. Additional studies were identified from related topics and related searches.

Because the initial literature search did not yield studies on the relationship between nurse executive empowerment, patient safety or self-efficacy in acute care settings, the search was expanded to include research on these topics that involved frontline nurses and midlevel nurse managers.

Inclusion and exclusion criteria

English-language studies, published in peer-reviewed journals from 1997 to 2014, were included in this review if they addressed

• the empowerment of staff nurses and/or nurse leaders;
• staff nurse perceptions of the effects of nurse managers’ behavior on the work environment;
• nursing-related issues on empowerment, patient safety, and self-efficacy
• acute care settings.

The choice of the time period is mainly associated with the increasing attention paid to empowerment and its effects on the nursing practice among researchers that marked the late 1990s (Greco et al., 2006). Articles were excluded if

• research did not address empowerment, patient safety, or nurse self-efficacy;
• non-nursing research on empowerment, patient safety, and self-efficacy did not directly apply to nursing or hospital environments;
• research on patient or family self-efficacy did not concern nursing or hospital environments; and
• research involved quality improvement projects.

Editorials were excluded.

Search Outcomes

A final sample of 25 research articles was selected for this integrative literature review. Articles on nurse executives were not found. Below is a brief description of the designs and limitations of the studies selected.

Patient safety

Articles on this topic included one literature review and four self-report survey questionnaires. Limitations included longitudinal study designs in which historical events may have influenced the results, cross-sectional designs that precluded determination of causality, and nonrespondent data not being known (Auer et al., 2014; Laschinger, Finegan, Shamian, & Wilk, 2001).

Nurse empowerment

Articles on this topic included a meta-analysis, an integrative review, a systematic review, a mixed research design study, a qualitative study, and 10 studies that used self-report survey questionnaires. Some of the limitations of these studies included heterogeneity, homogeneity, restricted geographic area, cross-sectional designs that precluded statements of cause and effect, and mixed population of acute care providers; these limitations constrain or preclude generalization of the studies’ findings (Kuokkanan & Katajisto, 2003; Koukkanen, Leino-Kilpi, & Katajisto, 2003; Laschinger, Almost, & Tuer-Hodes, 2003; Laschinger, Finegan, & Wilk, 2011; Morrison, Jones, & Fuller, 1997). Between-study variation in conceptualization and measures presents methodological issues that limit the validity and generalizability of the studies’ findings (Lee & Cummings, 2008).

Nurse self-efficacy

Articles on this topic included a meta-analysis, a qualitative study, and three self-report survey questionnaires. Limitations included a 15-month lag that made it difficult to determine whether historic events may have influenced the data (LeBlanc, Schaufeli, Llorens, & Nap, 2010). Small sample sizes and homogeneity (i.e., restriction to a single nursing specialty) constrained generalization of study findings and conclusions (Gloudemans, Schalk, & Reynart, 2013). The meta-analysis had a large number of subjects, but the researchers conceded that measurement errors and lack of reliability testing for measurement tools are not uncommon (Franklin & Lee, 2014).

Review of the Literature

Nurse Empowerment

The literature search revealed a scarcity of information specific to understanding how nurse executives experience and perceive empowerment in their role in the hospital setting. However, Laschinger offers extensive research (Laschinger, Finegan & Shamian, 2001; Laschinger, Finegan, Shamian, & Wilk, 2001; Laschinger, 1996; Laschinger & Havens, 1996) on the phenomenon of empowerment of nursing staff and on the unit leaders’ ability to promote an empowering work environment. Laschinger has used Kanter’s (1977) organizational theory as a foundation for clarifying the ways in which empowerment is understood and maintained by nursing staff as well as how empowerment is used effectively by nursing leaders (Laschinger, Purdy, & Almost, 2007; Laschinger, Sabiston, & Kutszcher, 1997). This integrative review includes the analysis of four articles that discussed the role of the clinical nurse managers (also known as midlevel managers), in their role as leaders in transforming work environments. Two additional research articles are included as well, because the research involved nurse managers and empowerment.

It was found that frontline nurses perceived effective leadership on the unit level as a source of empowerment for staff (Laschinger, Finegan, & Wilk, 2011; Laschinger, Wong, McMahon, & Kaufman, 1999). For nurse managers at work in their clinical units, being visible and accessible was seen as important for both staff and patients. Unit-level managers who provided resources and demonstrated support by being present on the unit while listening and addressing concerns voiced by frontline staff helped to create a supportive work environment. In addition, the data did show that supportive work environments promote better patient care with improved outcomes (Laschinger, Finegan, and Wilk, 2011; Laschinger, Wong, McMahon, & Kaufman, 1999). Also, in comparison with nurse managers who did not feel empowered, nurse managers who felt empowered had lower burnout rates and had higher job satisfaction (Laschinger, Finegan, & Wilk, 2009; Laschinger, Wong, McMahon, & Kaufman, 1999).

Perceptions of empowerment and organizational support predicted nurse managers’ job satisfaction (Patrick & Laschinger, 2006; Lee & Cummings, 2008). Job satisfaction—the extent to which a person’s hopes, desires, and expectations about their employment are fulfilled—is often used to help measure empowerment (Coomber & Barriball, 2006). Lee and Cummings (2008) found the theme of organizational support from nurse executives within the institution was a significant contributing factor to frontline managers’ perceptions of empowerment. In addition, empowerment of leaders at the unit level had a positive association with perceived job satisfaction of frontline staff as well (Lee & Cummings, 2008; Morrison, Jones, & Fuller, 1997). Although empowerment of unit leaders was shown to improve work satisfaction for frontline nurses as well, it does not discuss the nurse executive leaders to whom nurse managers report to. However, recognition of the importance of nursing leadership and the impact nurse leaders have on staff appears to be important at all levels within the organization.

Nurse executive support is consistent with the organizational theory described by Kanter (1977), an expert in the field of organizational behavior. Organizational empowerment discusses leadership support and employees’ job satisfaction is closely associated. Lee and Cummings (2008) concluded that increased job satisfaction was perceived when midlevel managers were supported by nurse executives. Midlevel managers indicated support that allowed their involvement in decision making was important and increased their sense of empowerment. In addition, increased job satisfaction correlated with higher recruitment and retention rates of midlevel managers.

Research that focused on the concept of empowerment and elements that contribute to empowerment in nursing was discussed in three papers (Kokanee & Katajisto, 2003; Kuokkanen, Leino-Kilpi, & Katajisto, 2003; Rao, 2012). Empowerment is often referred to when describing nurses who are able to deliver effective patient care (Rao, 2012). The literature indicates that empowerment is an evolving process of interactions among individuals, organizational, and sociocultural factors (Rao, 2012). A perceived sense of frontline staff nurses’ empowerment identified improved nursing practice that leads to improved patient care (Kuokkanen & Katajisto, 2003; Kuokkanen, Leino-Kilpi, & Katajisto, 2003; Rao, 2012).

Work-related empowerment components such as job satisfaction, self-esteem, career awareness, the availability of training that facilitates higher learning (i.e., medical/surgical nurse completes critical care training), employment status (i.e., benefitted position verses non-benefitted position), and self-perceived commitment to their nursing role are commonly identified as important to nurses’ perceptions of empowerment (Koukkanen & Katajisto, 2003; Kuokkanen, Leino-Kilpi, & Katajisto, 2003). These researchers also identified factors that appear to impede empowerment—for example, dictatorial leadership and lack of access to essential information. Overall, the teams of investigators agreed that empowerment is a useful concept that can add to our understanding of professional growth and development in nursing (Koukkanen & Katajisto, 2003; Kuokkanen, Leino-Kilpi, & Katajisto, 2003; Rao, 2012).

Job satisfaction is not only a consideration for mid level management but can contribute to staff engagement and staff empowerment which are important considerations in health care studies today (Johnson, 2009). Three articles discussed job satisfaction and staff engagement that increase staffs’ perceptions of empowerment. Job dissatisfaction can contribute to staff disengaging in their work environment because they are not happy with the environment; in addition they are often absent from work and are not empowered to contribute to safe, high-quality patient care (Johnson, 2009; Zangaro & Soeken, 2007). Inpatient work environments, with increasing workloads that take away from patient care are stressful (Zangaro & Soeken, 2007). Creating a work culture in which nurse executives promote nurse-physician collaboration and decrease job stress while nursing autonomy is encouraged, ensures the delivery of safe, high-quality patient care, high patient satisfaction rates, positive patient outcomes, and staff who are engaged and want to come to work is crucial for patient care (Johnson, 2009; Zangaro & Seen, 2007).

Nurses who are engaged in their work are able to voice their concerns when a process is not working. For example, Laschinger, Almost, and Tuer-Hodes (2003) found that nurses in magnet hospitals tended to communicate freely and report medical errors or any cases that could enhance the delivery of care. The researchers stressed that the nurses working at magnet hospitals enjoyed a considerable degree of autonomy, which was found to contribute to voicing various issues and concerns (Laschinger et al., 2003). These nurses also appear to be more satisfied with their work, and this greater satisfaction is associated with fewer instances of reported burnout (Halbesleben, Wakefield, Wakefield, & Cooper, 2008; Laschinger et al., 2003). On the contrary, Halbesleben et al. (2008) found that nurses who reported a significant level of burnout were likely to silence cases that did not result in serious negative health outcomes for patients, which had an adverse effect on the provision of healthcare services as the learning and knowledge sharing did not occur. In addition, performance improvement initiatives involving frontline staff nurses empowers the nurses because they are involved in improving the patient care they deliver daily (Laschinger et al., 2003). Empowerment is the overarching concept that appears to have positive influence on the actions of frontline staff nurses.

Empowerment of frontline staff nurses is an area where patient safety is vital (Laschinger & Finnegan, 2005). Two studies selected for this review examined empowerment of both frontline nursing staff and midlevel nurse managers. Consistent nursing staff -midlevel managers and frontline staff nurses- with minimal turnover helps to create an environment that promotes safe patient care. A workforce can be more readily sustained when staff nurses trust and respect their managers (Laschinger & Finnegan, 2005; Laschinger, Finegan, & Wilk, 2009). In addition, frontline staff nurses’ job satisfaction was found to be higher when trust in management was reported by frontline staff nurses. Frontline staff nurses empowerment perceptions impacts beliefs about fair management practices and perceptions of being respected at work, higher perceptions of empowerment correlated with positive perceptions of management (Laschinger & Finnegan, 2005; Laschinger, Finegan, & Wilk, 2003). As a result, job satisfaction and commitment to frontline staff nurses’ place of employment was higher when structural empowerment perceptions were higher. A consistent workforce decreases turnover and is easier to sustain when working conditions empower frontline staff nurses (Laschinger & Finnegan, 2005; Laschinger, Finegan, Shamian, & Wilk, 2001).

Nurse empowerment is an important factor in a hospital’s acquisition of Magnet status from the American Nurses Credentialing Center (Laschinger, Almost, & Tuer-Hodes, 2003; Upenicks, 2003). A primary characteristic of Magnet hospitals is the involvement of the frontline staff nurses in the decision making that directly affects bedside practice. This participation of frontline staff nurses in decision making is often referred to as shared governance (Upenicks, 2003).

Quantitative and qualitative results supported Kanter’s theory of work empowerment structures (e.g., access to information, support, resources needed to perform roles, and opportunity to grow and learn in employed role), create the potential for frontline staff nurses and nurse leaders to be more empowered (Laschinger, Almost, & Tuer-Hodes, 2003; Upenicks, 2003). Empowered employees perceive more autonomy at work; employees’ belief that they have more autonomy in turn increases the employees’ job satisfaction (Laschinger, Almost, et al., 2003; Upenicks, 2003). Overall this quantitative and qualitative research revealed that RNs employed at Magnet designated hospitals reported higher levels of empowerment and job satisfaction than RNs employed at a non-Magnet hospital.

Upenicks found that “the quality of nursing leadership” is a key organizational characteristic indicative of job satisfaction (p. 86). In addition, visibility and accessibility of nurse managers and nurse executives was found to be important to frontline staff nurses. Quality nursing leadership promotes a relationship of mutual respect between leaders and staff members and facilitates communication that is empowering to both. In addition, a nurse executive who empowers her or his managers’ makes available resources and the time needed to promote work effectiveness in the acute care setting (Laschinger et al., 2003; Upenicks, 2003).

Patient Safety and Empowerment

Safety in the hospital is of primary concern for leaders, care providers, patients, and patients’ families. Furthermore, in nurse executives’ efforts to find ways to improve patient outcomes, frontline staff nurses can play a key role. Leadership has also shown to have an impact on patient safety. Auer et al. (2014) concluded that nurse leader support at the executive and management levels created “trust in management” (p. 26). Nurse executive support—specifically communication involving patient safety such as nurse executive patient safety rounding—was correlated with nurses’ reporting higher perceptions of patient safety in the work environment. Communication about safety practices, non-punitive responses to errors, open communication, and organizational learning and reporting of errors were important aspects of reported higher perceptions about patient safety. The study’s findings did substantiate the importance of nurse executives’ ability to empower frontline staff nurses to augment patient safety. Laschinger, Wong, Cummings and Grau (2014) also emphasized that nursing leadership was vital for nurses’ empowerment that was closely related to patient safety. The researchers found that the supportive leadership that contributed to the development of trusting relationships among nursing professionals enhanced nurses’ job satisfaction and resulted in their empowerment, which, in its turn, was associated with improved performance and enhanced patient safety (Laschinger et al., 2014). Wong and Giallonardo (2013) focused on the correlation between nurses’ empowerment and patient safety as seen by nursing professionals. The researchers stated that nurses valued authentic leadership that (in their view) was closely associated with lower frequencies of negative health outcomes for patients. This study contributes significantly to the knowledge base concerning nurses’ empowerment and patient safety as it unveils nursing professionals’ views on the correlation between patient safety and empowerment. These views can be used to estimate nursing professionals’ engagement and response to empowering practices.

Increasingly, nursing empowerment has been associated with patient safety. A literature review by Richardson and Storr (2010) highlighted nurses’ central role in patient safety. While recognizing that their study had limitations, the investigators were nevertheless able to identify multiple ways in which nurse empowerment substantially improved patient safety. Patient safety can be compromised when nurses are physically and emotionally exhausted. This exhaustion can lead to nurses’ becoming “burnt out”, which can manifest as apathy and diminished self-confidence in their ability to perform clinical tasks; these affective impairments can in turn compromise patient safety (Richardson & Storr, 2010). It is necessary to note that researchers have developed various tools to make nurses’ empowerment possible in different clinical settings. An illustration of such efforts is the study involving the evaluation of a safety score tool. Soto and Yaldou (2015) evaluated the effectiveness of the Michigan Opioid Safety Score (MOSS) and found that the tool that had been introduced comparatively recently was efficient in nurses’ empowerment. Importantly, the tool was instrumental in enhancing patient safety.

Nurse Self-Efficacy and Empowerment

In the nursing literature, the focus of research on self-efficacy has been the patient—specifically, how patients’ self-efficacy mediates improved involvement in their own care as well as better outcomes for recovery. The literature search conducted for this review found no studies that have investigated nurse leader self-efficacy. Also, few studies have investigated nurses’ self-efficacy on the type and manner of nursing care and on consequent patient outcomes. Because the studies were very different in their approach to understanding nurse self-efficacy, they are discussed separately.

LeBlanc, Schaufeli, Salanova, Llorens, and Nap (2010) reported that, over time, a reciprocal relationship was found between ICU nurses’ self-efficacy beliefs and enhanced team collaboration. LeBlanc et al. found that strengthening self-efficacy enhances collaboration and collaboration (specifically, high-quality collaboration) strengthens self-efficacy, which in turn improved the work environment. LeBlanc et al. (2010) concluded that work environments can be conducive to professional self-efficacy. Such a work culture—in which collaboration and self-efficacy are mutually supporting—promotes empowerment, because communication and teamwork facilitates the delivery of safe patient care among health professionals.

Gloudemans, Schalk, and Reynart (2013) surveyed mental health nurses to identify relationships between critical thinking skills and self-efficacy beliefs. The researchers found that educational levels were correlated with critical thinking skills but not with self-efficacy beliefs; self-efficacy beliefs were correlated with years of nursing experience but not with educational levels. From these findings, we can deduce that over time, accumulation of clinical experience resulted in the nurses’ acquisition of nursing knowledge.

Winslow, DeGuzman, Kulbok, and Jackson (2014) performed a study to identify an association between nurses’ academic advancement and their sense of self-efficacy. The investigators’ finding that length of nursing experience and strength of self-efficacy belief were not correlated was opposite the finding of Gloudemans et. al. (2013). However, Winslow et al. did find that attainment of nursing degrees beyond diploma or ADN was positively correlated with strength of self-efficacy belief.

Bandura (1977) speculated that the ability to learn new skills well and to successfully perform those skills enhances positive self-efficacy beliefs. Learning something and performing it well reinforces positive thoughts about one’s abilities. Franklin and Lee (2014) performed a meta-analysis of studies that compared simulation learning and traditional didactic learning in terms of their effects on self-efficacy. The meta-analysis of 38 studies found that for new nurses, simulation training was more effective for strengthening self-efficacy than was traditional didactic lecture.

Fry and MacGregor (2014) conducted a study to understand the nature and effects of emergency room (ER) nurses’ confidence on their clinical decision making. The researchers concluded that acquiring self-confidence is important for improved clinical decision making. Fry and MacGregor’s findings also suggested that confidence that was related to self-efficacy enabled nurses to successfully complete nursing tasks required for patient care. The study’s participants were experienced ER nurses whose clinical acumen may have been different from ER nurses with less experience. Training that promotes nurses’ self-efficacy also strengthens their self-confidence. Ensuring that nurses are thoroughly trained for the clinical area they will be working in is the foundation for developing confidence in their patient care delivery. In this regard, nurse executives must ensure the availability of training programs that will support nurses’ success in their jobs.

State of Knowledge

Although research has shown that empowerment improves nursing care, significant deficits in researchers’ understanding of empowerment remain. In the literature there were no direct links to outcomes for patient safety influenced by nurse executive empowerment. Specifically, researchers should conduct research on nurse executive empowerment and the link to patient safety that explores the potential relationship nurse executives have in influencing patient safety at the bedside. To fully understand nurse executive empowerment, research needs to understand both the nurse executive’s perceptions of empowerment as well as facilitators and barriers to perceived empowerment.

As a body of work, limitations to research on empowerment have not explored the linkages between empowerment, nurse self-efficacy, and patient safety. The literature implies when frontline staff are empowered by their nurse manager and when nurse managers are empowered by their nurse director the perceptions of improved safer care for patients increases significantly which leads me to believe nursing leadership can influence improved patient care. To date, research has focused on understanding empowerment and the influence it has on nursing care but potential relationships between nurse executives and the influence nurse executives have on the delivery of safe patient care by frontline staff nurses on outcomes have not been identified and explored. As research has shown, empowerment has structural determinants and psychological components, but the effect of nurse executive empowerment on outcomes and, even more specifically, potential relationships between nurse executive empowerment on patient safety have not been examined.

Laschinger and colleagues have been instrumental in adapting Kanter’s work to organizational empowerment in nursing, but the link to patient safety is not clear. Laschinger’s initial work sought to test models for the structural determinants of empowerment to nursing. Historically, during the mid to late 1990’s, the Canadian healthcare system was undergoing major restructuring, and this restructuring resulted in reduction of nurses’ job satisfaction due to increased workloads and uncertainty in the direction of healthcare overall (Laschinger, 1996). In addition, the nursing shortage was imminent and future shortages were worrisome for nursing care in general (Laschinger, 1996). Although Laschingerw and others have investigated nurse managers and how their empowerment influences frontline staff nurses, research on nurse executives and empowerment has not been done. Moreover, outcomes of empowerment, such as safe patient discharges or error-free medication administration, have not been studied.

Research on the impact of empowerment on frontline staff supports that empowerment is an important construct for improved nursing care that ultimately leads to safer patient care. For instance, research on acute care hospitals characterized as having nurses actively involved in governance over nursing practice have higher perceptions of patient safety by frontline staff nurses (Upenicks, 2003). In addition, research indicates that nursing leadership plays a key role in these types of hospitals (Upenicks, 2003). Although research indicates a correlation between patient safety and empowerment, it still leaves a deficit in our understanding of how nurse executives perceive their own barriers and facilitators of empowerment.

Patient safety is inherently important to patients, families, and providers of patient care. Some researchers have sought to understand how empowerment contributes to safer environments, especially as related to Magnet designated hospitals. Research also implies that patient safety and empowerment are linked. However, the processes by which nurse executives become empowered and employ their empowerment remains unclear—as does the relationship between nurse executive empowerment and safer patient care cultures.

Research has found patient safety decreases and patients are at risk for errors to occur when nurses are not engaged (Johnson, 2009; Zangaro & Soeken, 2007). Job satisfaction decreases when nurses are not engaged and nurses report higher levels of stress and burnout (Laschinger, Finnegan, Shamian, & Wilk, 2003). Patient safety improvements would be difficult to implement in the acute care setting because the ability to influence and to be influenced is diminished when frontline staff nurses are stressed out and burnt out therefore less engaged and satisfied with their jobs. Although frontline staff nurses perceived structural determinants of empowerment in place improved the perception of patient safety within hospital units, (Laschinger, Finnegan, Shamian, & Wilk, 2003), research about nurse executive influence for patient safety on the unit level has not been studied.

Nurse self-efficacy research has primarily focused on staff nurse empowerment and patient empowerment as it pertains to patients’ involvement in their own care. Studies looked at nurses’ self-efficacy as discussed, (Fry & Macgregor, 2014; Winslow, DeGuzman, & Kulbok, 2014) but no research has investigated self-efficacy as experienced by nurse executives. Also, no studies have examined how self-efficacy may or may not influence nurse executive empowerment.

Furthermore, no studies have investigated potential relationships between patient safety, nurse executive empowerment, and self-efficacy. Research on these relationships could shed light on (a) the influence of nurse empowerment on nurses’ perceptions, attitudes, and behaviors regarding patient safety and (b) nurse executives’ influence on patient safety. Such research could have important clinical implications for both patients and care providers.

Clinical Implications

Health care is changing rapidly. Since publication of the initial Institute of Medicine (2001) report that alerted the public to seriousness of medical error in U.S. health care—and with recent research (Page, 2004; James, 2013), showing that the magnitude of medical error is even greater than previously thought—concern for patient safety has risen to the forefront of patient care. In addition, the need for cost effective healthcare for all is imperative. The Patient Protection and Affordable Care Act signed by President Obama in March 2010 has been the most significant change to health care since the institution of Medicare in 1965 (Manchikanti et al., 2011). Clearly, patient care must be cost-effective, effective, and safe.

Empowerment at all levels of the nursing staff supports a hospital’s operation in accordance with Magnet principles and objectives—including maintenance of a culture of safety. Patient safety as an outcome of patient care is a vital component of patient care. Research that leads to a fuller understanding of how hospitals and clinicians can assure patient safety has significant clinical implications, for both patients and providers. Because nurse executives are the leaders in acute care organizations, research that focuses on their perceptions of empowerment and how their empowerment (or lack thereof) affects patient safety outcomes is vital for all stakeholders.

Recommendations for Future Research

The goal of my research is better understanding of nurse executive empowerment. Although my initial small pilot qualitative research was limited to five interviews, in analyzing the data, some of this study’s findings indicate that further data collection is warranted. Key concepts that emerged from the data analysis include

• For nurse executives, behaviors and actions that support empowerment included skilled communication techniques (e.g., taking time to listen and acknowledging what is heard) and being present in the nurse executive role.
• Nurse executives’ descriptions of empowerment varied in level and type across the range of hospital structure. For example, because of their position in the hospital organization, many chief nursing officers perceived empowerment to be a fundamental part of their professional responsibility. In addition, part of the chief nursing officer’s ability to empower others and their own sense of empowerment depended somewhat on the organizational structure.
• Individual and system barriers and facilitators to empowerment were also identified in my pilot study. Individual facilitators included personal values and beliefs about nursing as a profession. System barriers were often dependent on the leadership organizational structure – regional offices guiding direction verses a non-medical board of directors who did not provide much direction.

Due to the paucity of research on nurse executive empowerment and the potential connection to outcomes such as patient safety, research focused on understanding nurse executive empowerment is vital to lending understanding to patient safety in our current health care systems. Qualitative research that seeks to learn and understand this important phenomenon using a grounded theory approach will add to our knowledge and increased understanding of empowerment in nursing practice.

Conclusion

Hospitals are complex. Acute care hospitals—where frontline bedside nurses are expected to deliver safe, high-quality patient care—are extremely complex organizations. A hospital’s complexity manifests both at the individual caregiver level, that is, in the diversity of health care occupations, and at the system level (e.g., medication delivery system, electronic medical record system, and ordering supply system; James, 2013). The role of nursing executives is also very complex, daunting, challenging and exciting all at the same time. The nurse executive’s role provides an extraordinary opportunity to influence patient care in a very broad context. Although nurse executives are not at patients’ bedside, nurse executives are nevertheless responsible for creating a system that promotes safe, quality patient care. Further research is needed to bridge the gap that currently exists between nurse executive empowerment, self-efficacy, and the potential connection to patient safety as discussed throughout this literature review. My dissertation will work towards addressing the gaps that currently exist.

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