Empowerment and Safety in Nurses Art

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Structural Empowerment and Patient Safety Culture of Nurses Working in Critical Care UnitsClinical Science Research

Structural Empowerment and Patient Safety Culture of Nurses

Working in Critical Care Units

Donna ArmellinoRN; Division of Infectious Diseases, Department of Medicine, North ShoreUniversity Hospital

Introduction

Medical errors have become a major national concern. The Institute of Medicine (IOM)reported in 1999 that an estimated one million people are injured by errors in treatment athospitals in the United States, with an estimated 120,000 deaths arising from those errors (Kohn,Corrigan, & Donaldson, 2000). Preventable events that cause errors resulting in pain andsuffering are reported in the media, on television and broadcast radio, and in newspapers andjournals. Unfortunately, these are reports of patients who came to the hospital for care and wereharmed by that care (Donchin et al., 2003; Hayward & Hofer, 2001).

Medical errors are failed processes that are clearly linked to adverse outcomes (Hofer &Kerr, 2000). Human error may be the result of system failures related to how a process is

designed, the structure of the organization, incompetence due to employee experience andtraining, or related to equipment failure. Systems are created and supported by leaders within anorganization. Leaders can redesign workplace processes, structures, training, and equipmentmaintenance procedures to eliminate medical error resulting from human error. Errors decreaseand safety increases when human error is considered within system design (Galvan, Bacha,Mohr, & Barach, 2005).

Safety can be considered when an individual is protected from accidental injury (Kohn atal., 2000). High-risk industries, such as aviation, are making use of human factor engineering(HFE). Using a human error approach, safety improvements have been demonstrated in aviationby improving systems (Wiegmann, Zhang, von Thaden, Sharma, & Mitchell, 2004). With HFE,it is assumed that people make errors and that systems are devised to control for human error.

In health care, the work environment has been redesigned to decrease medical errors andincrease safety. Creating processes that factor in human error has had a positive influence onmedical errors involving medication administration, anesthetic practices, specimen mislabeling,drug events, wrong site surgery, hospital-acquired infections, and surgery (Cooper, Newbower,Long, & McPeek, 2002; Galvan et al., 2005; Micheals et al., 2007; Pronovost et al., 2006;Quillen & Murphy, 2006). Decreasing errors through redesign of the registered nurses (RNs)work environment has increased patient safety.

Changing the nurses work environment has been shown to influence patient outcomes.Needleman, Buerhaus, Mattle, Stewart, and Zelevinsky (2002) used administrative data from 799hospitals in 11 states to report the relationship between increased hours of nursing care per dayby RNs and rates of adverse outcomes. Aiken, Clarke, Sloane, Sochalski, and Silber (2002)associated patient-to-nurse ratios and patient mortality rates among 232,342 adult patientsdischarged from two hospitals in Pennsylvania. Whittaker, Smolenski, and Carson (2000)discussed increased medical errors in patients when care is rendered by nurses who are notcertified. Research involving 866 surveys from nurses in 25 critical care units within eighthospitals in southeastern Michigan suggested that lack of power may contribute to less desiredpatient outcomes (Manojlovich & DeCicco, 2007).

It has been reported that empowered nurses report a high quality of nursing care on theirunits (Upenieks, 2003), and nurses with increased authority on issues such as safety, cost

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effectiveness, and care exhibit increased empowerment (Parsons, 1998). Health care, likeaviation, is a potentially hazardous industry vulnerable to human error. Healthcare leaders canlearn from systems initiated in aviation by analyzing events leading to medical errors and changethe work environment to control for human error.

Adoption of principles from other industries and integration of these principles into

health care can accelerate progress toward a supportive work environment that facilitates apatient safety culture. A culture of patient safety is a work environment with employees whovalue, believe, practice, and exhibit behaviors and attitudes of safety (Agency for HealthcareResearch and Quality, 2003). According to an integrative review on patient safety cultureperformed by Wiegmann et al. (2004), indicators of a patient safety culture includeorganizational commitment, management involvement, employee empowerment, rewardsystems, and reporting systems.

Organizations that provide health care have a responsibility to deliver safe care. Ahealthcare organization must utilize organizational strategies to reduce and eliminate errorsrelated to human error (Galvan et al., 2005). One potential strategy is to support structuralempowerment within the nurses work environment to create a culture of patient safety

(Armstrong & Laschinger, 2006).Organizations that demonstrate a culture of safety have employees who perceivethemselves as empowered and function autonomously. Such organizations have a commitment topromote a proactive approach in decision making on safety initiatives and processes (Laschinger,1996). Organizations with an institutional infrastructure of employees who are committed totheir organization and hold themselves accountable for the provision of safety promote a cultureof safety (Armstrong & Laschinger, 2006; Wiegmann et al., 2004).

The IOM released a report in 2003 titledKeeping Patients Safe: Transforming the WorkEnvironment of Nurses. This report highlights the positive association of the nurses workenvironment and quality of patient care. Issues in this report include concerns about poorlydesigned processes of care, lack of support systems for decision making, and lack of a structuredenvironment in which nurses work (Page, 2004). All these issues, independently or incombination, contribute to error. Errors, in any industry, are often the result of a sequence ofevents. If the sequence of events is disrupted, the error is unlikely to occur.

Among the solutions proposed for improving the work environment is support for nursestructural empowerment to develop a patient safety culture that can disrupt these sequences andthereby reduce errors. Structural empowerment is the ability to access support, information,resources, and opportunities from ones position in the organization (Laschinger & Havens,1996). Structural empowerment can be viewed as a necessary feature of a nurses workplaceenvironment. Quality of the work environment affects feelings of organizational support, accessto resources, organizational commitment, trust, and improved quality of patient care (Laschinger,2008; Laschinger, Finegan, & Shamian, 2001; Matthews, Laschinger, & Johnstone, 2006;Patrick & Lachinger, 2005).

Armstrong and Laschinger (2006) linked the quality of nurse practice environments to aculture of patient safety. Based on the results of their study, they suggested that empowerednurses practice safely due to workplace conditions that promote provisions for providing safepatient care. In another study, Upenieks (2003) reported that nurses who feel empowered in theirwork environment are more satisfied, committed to the organization, and report high qualitynursing care on their units.

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Healthcare organizations have prioritized safety as a goal. Leaders within organizationsthat provide an empowering nurse environment can achieve the organizations goal by providinga constructive organizational culture (Valadares, 2004). The creation of an empowering nursingenvironment influences the nurses perception of a culture of safety (Armstrong & Laschinger,2006). Logically, one can expect a reduction in medical errors when nurses have a positive

perception of structural empowerment and patient safety culture.

Methods

A descriptive, correlational design was used to report the relationship between structuralempowerment and culture of patient safety. This study was conducted in the adult critical careunits in an 812-bed tertiary hospital in New York. The five critical care units have a total bedcapacity of 85. They include a 16-bed neuroscience care unit (NSCU), an 18-bed surgicalintensive care unit (SICU), a 17-bed medical intensive care unit (MICU), a 12-bed coronary careunit (CCU), and a 22-bed cardiothoracic care unit (CTU). Patients 18 years of age and older arecared for on all units.

A convenience sample of 102 RNs with active work status assigned to the cost centers for

the NSCU, SICU, MICU, CCU, and the CTU was surveyed from an estimated population ofnurses available was 257 (200 full-time, 41 part-time, and 16 per diem). The instruments used inthis study were a background data sheet, the Conditions of Workplace Effectiveness (CWEQ-II)(Laschinger et al., 2001), and the Hospital Survey on Patient Safety Culture (HSOPSC) (Sorra &Nieva, 2004a). The three anonymous surveys with no identifiable information were distributedwith the RNs paycheck with a cover letter. The RNs were provided four weeks after distributionto complete the survey. Informed consent was assumed on receipt of the completed survey.There were no direct benefits to the participant or the units involved in this study, participantswere not compensated for their participation.

The background data questionnaire included 11 questions focused on: gender, birth year,race, years in nursing, years at hospital, highest degree held, certification in specialty area, typeof certification, job status, the number of hours worked per week, plus a question on salary. Thereadability of the tool, based on the Flesch-Kancaid Index, is 7.7. It took no more than 5 minutesto complete.

The CWEQ-II, instrument contains 19 questions, plus two additional items that measureglobal empowerment for the purpose of construct validation. The instrument measures sixcomponents of structural empowerment perceptions of access to opportunity, information,support, and resources (Laschinger et al., 2001). Two additional scales, the Job Activities Scale II (JAS-II), and the Organizational Relationships Scale-II (ORS-II) measured formal power andinformal power (Laschinger et al.).

The scoring for the CWEQ-II, JAS-II, and ORS-II incorporates a 5-point Likert-scale,with scores ranging from none to a lot for each item. The questions are positively worded,and a higher score indicates a higher level of structural empowerment. Items are summed andthen averaged to obtain a subscale scoring range from 1 to 5. A total structural empowermentscore is calculated by summing scores for all six components. The sum and average of each ofthe subscales provide scores ranging from 1 to 5, which are then summed and averaged to createa total structural empowerment score. Structural empowerment scores range from 6 to 30 withthe higher number representing a higher perception of structural empowerment. Scores rangingfrom 6 to 13 are described as low levels of structural empowerment, 14 to 22 as moderate levelsof structural empowerment, and 23 to 30 as high levels of structural empowerment.

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The HSOPSC was designed to measure seven unit-level perspectives of patient safetyculture, three hospital-level aspects of patient safety culture, and three outcome variables, wasused to measure perceptions of patient safety culture. Twelve of the 14 subscales are rated on a5-point Likert scale. For 31 items, the ratings are 1 (strongly disagree), 2 (disagree), 3 (neither),4 (agree), and 5 (strongly agree). For 9 items, the ratings are 1 (never), 2 (rarely), 3 (sometimes),

4 (most of the time), and 5 (always). Two subscales request single-item measures. The patientsafety culture scales include: two outcome scales: (a) overall perceptions of safety; (b) frequencyof event reporting; two additional scales are measured via single item measures; and ten patientsafety culture scales: (a) supervisor/manager expectations and actions promoting patient safety;(b) organizational learning - continuous improvement; (c) teamwork within units; (d)communication openness; (e) feedback and communication about error; (f) non-punitiveresponse to error; (g) staffing; (h) hospital management support for patient safety; (i) teamworkacross hospital units; and (j) hospital handoffs and transitions(Sorra & Nieva, 2004b). Thesurvey takes 10 to 15 minutes to complete. Its Flesch-Kincaid grade level score for readability is8.2, indicating that an eighth grader should be able to easily read the survey.

Complete CWEQ-II and HSOPSC surveys were those in which 90% or more of the

CWEQ-II and HSOPSC instruments were completed. For questionnaires with less than 10%missing data, the mean score on that section of the questionnaire was imputed into the missingquestion. After all surveys were reviewed, the response rate was calculated. The responses to thesurveys answered three research questions:1. What are the perceptions of structural empowerment among nurses working in critical care

units?2. What are the perceptions of patient safety culture among nurses working in critical care units?3. What is the relationship between perceptions of structural empowerment and patient safety

culture among nurses working in critical care units?Results

Two hundred fifty-seven RNs received survey packets with their paychecks on August28, 2008. Data collection was conducted over a 4-week period and yielded 102 surveys. Theoverall response rate was 40%. The number of completed surveys exceeded the minimumnumber (N= 82) of participants needed for a medium effect size (=.30),a = 0.05, and power(1- ) = .80 (Burns & Grove, 2005).

The personal characteristics of the sample included gender, age, race, and years innursing. The majority of participants were female (n= 92, 90.2%); 10 were male (9.8%). Agesranged from 23 to 58 years, with the mean age 38.59 (SD 8.46) for the 96 RNs who respondedto this question (95%). Most participants were White/Caucasian (n= 50, 50%); 2 identifiedthemselves as American Indian/Alaskan (2%); 7 Asian (7%); and 9 each Black/African-American and Hispanic/Latino (9%). One participant identified as a Pacific Islander (1%), 5responded other (5%), and 17 (16.83 %) did not answer the question pertaining to race. Yearsof experience as a RNs ranged from zero to 36 years (n= 100). The mean number of yearsworked was 12.28, SD 8.57.

Participants were asked to provide information on their highest degree held, certificationin a specialty area, and type of certification. The majority (n= 59, 58.42%) had a minimum of a4-year degree. Twenty-seven (26.73%) of the participants had a diploma or an associate degreein nursing; 15 (14.85%) had a masters degree. Thirty-one (31%) had certification; and 69 (69%)did not have certification.

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Work-related characteristics included years worked at the hospital, full-time or part-timestatus, and two questions pertaining to salary. The number of years at the hospital ranged fromzero to 27 years with a mean of 9.33 (n= 98, SD= 6.74). Only RNs with a minimum of 8 weeksof employment participated in the survey process. The median number of years worked at thehospital was 8. Most particpants (n = 88, 86.27%) worked full-time; 14 (13.76%) worked part-

time/per diem. The salary range was from $60,000 to $129,000 (n =102); a majority ofrespondents indicated a salary increase in the past year (n= 59, 57.84%).Research Question 1. What are the perceptions of structural empowerment among

nurses working in critical care units?The CWEQ-II scores of the 6 subscales are summed to create the total structural

empowerment score (score range 6-30). According to Laschinger and colleagues (2001), scoresless than 14 indicate low levels of structural empowerment; scores ranging from 14 to 22indicate moderate levels of structural empowerment; and scores of 23 to 30 indicate high levelsof structural empowerment. The 101 respondents perceived themselves to be moderatelyempowered. The total structural empowerment score ranged from 12.00 to 28.17. A majority ofthe respondents (n= 80, 79.2%) indicated a moderate (14 -


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HSOPSC Dimension N M SD Range % Positive

Frequency of Events Reported 95 0.48 0.43 0.0 -1.0 47.72%

Overall Perception of Safety 98 0.50 0.31 0.0 -1.0 49.74%

Supervisor/Manager Expectations 98 0.69 0.36 0.0 -1.0 68.88%

Organizational Learning 98 0.68 0.33 0.0 -1.0 68.37%

Teamwork Within Units 98 0.74 0.33 0.0 -1.0 74.40%Communication Openness 98 0.61 0.4 0.0 -1.0 60.54%

Feedback and Communication About Error 98 0.60 0.38 0.0 -1.0 60.37%

Non-Punitive Response to Error 98 0.21 0.32 0.0 -1.0 21.09%

Staffing 98 0.40 0.29 0.0 -1.0 39.12%

Hospital Management Support for PatientSafety

98 0.52 0.39 0.0 -1.0 52.38%

Teamwork Across Units 98 0.43 0.36 0.0 -1.0 42.35%

Hospital Handoffs and Transitions 98 0.40 0.35 0.0 0.94 43.37%

Each participant gave the hospital a safety grade. Fifteen (19.74%) indicated a safety

grade of A for patient safety; 50% of the respondents (n= 38) indicated a grade of B; and 23(30.3%) gave a grade of C or D. No participant gave an E, a failing grade, for safety. Amajority (62.5%) did not report an event that almost caused or caused a medical error within thepast 12 months; 30 (37.5%) reported 1 to 7 events with a majority reporting fewer than 3 events(31.25%).

Research Question Three. What is the relationship between perceptions of structural

empowerment and patient safety culture among nurses working in critical care units?The CWEQ-II total structural empowerment score and the percent positive for each scale

on the HSOPSC instrument were analyzed using a Pearson correlation coefficient. Correlationresults are listed in Table 2.Table 2. Correlation between Total CWEQ-II Score and HSOPSC Scales (N= 98)

HSOPSC Dimension Total Empowerment Score

Frequency of Events Reported 0.01

Overall Perception of Safety 0.32*

Supervisor/Manager Expectations and Actions 0.26 *

Organizational Learning and Continuous Improvement 0.34**

Teamwork Within Units 0.35*

Communication Openness 0.28**

Feedback and Communication About Error 0.41***

Non-Punitive Response to Error 0.19

Staffing 0.27**

Hospital Management Support for Patient Safety 0.18

Teamwork Across Units 0.24*

Hospital Handoffs and Transitions 0.13

Note: *p < 0.05, **p < .01, *** p < .001

Discussion

This study had a 40% response rate. The low response rate could be related to the lengthof the surveys, completion of a hospital survey within the past two months, concern that the

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survey results could be traced to their identity, and past experience with surveys, results are notshared with the participants.

The demographic characteristics of the 102 RNs who participated in this study werecompared respondents to the 2004 National Sample Survey of Registered Nurses (NSSRN)conducted by the U.S. Department of Health and Human Services Health Resources and Service

Administration (HRSA). A majority of the participants were White, and most were femalesbetween 23 to 58 years of age (M = 38.59). The average age in the present study was less thanthat of the RNs included in the NSSRN (M= 46.8). A majority of the RNs in this study (70.15%)had an education that exceeded a diploma in nursing or an associates degree; for the NSSRN, therate was 47.2%. Participants in this study worked full-time and earned a salary that exceeded theaverage annual earnings of RNs indicated in the HRSA report ($57,785).

A majority of RNs in this study population (n= 80, 79.21%) perceived themselves to bemoderately empowered. The mean structural empowerment score in this study was 20.55 (N=101), which translates to a moderate level of structural empowerment. Nurse structuralempowerment has been studied extensively by Laschinger and colleagues at the University ofWestern Ontario utilizing the CWEQ-II instrument. Researchers have reported structural

empowerment scores among RNs in various health care settings ranging from a minimum totalstructural empowerment score of 17.35 to maximum score of 20.04 (Laschinger et al., 2001;Donahue, Piazza, Griffin, Dykes, & Fitzpatrick, 2008).

The total structural empowerment score in the present study was higher than the totalstructural empowerment score in the research conducted by Armstrong and Laschinger (2006) inwhich structural empowerment was related to characteristics of a magnet hospital. The higherstructural empowerment of the nurses in the present study may be related to current efforts toattain magnet recognition. The score was higher than that reported by Donahue at al. (2008) andlower than that reported by Piazza et al. (2006) for a study population of staff nurses, advancedpractice nurses, and nursing administrators. Differences in these total structural empowermentscores may be related to geographic region, management commitment to provide access toopportunity, information, support, and resources, or the diversity within the groups surveyed.

The total structural empowerment score among RNs was higher in the present study thanin previous research (Matthews et al., 2006). The elevated scores may be related to the nurseexecutives key role of active participation in the organizations management team and focusedefforts toward creating an environment that affects empowerment structures. Nurses who feeltheir work environments are empowering are more satisfied, are committed to the organization,and report high quality nursing care in their units (Laschinger et al., 2004; Laschinger et al.,2000; Laschinger, Finegan, Shamian, & Wilk, 2003; Laschinger & Havens, 1997). Increasingperceptions of structural empowerment by providing a structurally empowering environment canaffect RNs decisions about their patients plan of care and the degree to which they have anactive and central role in organizational decision making. The environment in which RNs workaffects their perceived structural empowerment. The degree to which these variables are relatedto perceptions of structural empowerment may warrant additional research.

Perceptions of the culture of patient safety have been assessed in long-term care andacute care settings (Castle, 2006; Castle at al., 2007; Hellings et al., 2007; Scherer & Fitzpatrick,2008; Sorra & Nieva, 2004a). The HSOPSC survey has been used with various healthcareworkers, including ancillary staff, management staff, physicians, and administrators. Eachgroups perceptions of patient safety culture may differ. In a study performed by Hannah andcolleagues (2004), a project funded under a cooperative agreement with the AHRQ,

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administrators had a tendency to indicate higher scores on the patient safety scales than staff.Studies conducted exclusively among RNs in the critical care units using the HSOPSC have notbeen reported in the literature. The present study provides the most comprehensive informationavailable on RNs nurses working in critical care.

The higher responses in this research study and the study conduct by Sorra and Nieves

(2004a) were similar for teamwork, communication openness, supervisor/manager expectations,organizational learning, and continuous improvement. The response rate in this research studymay be related to the development of a rapid response team. This team consists of RNs from theacute care setting and other clinicians from other disciplines who respond to a patient based onthe patients care needs prior to the situation becoming critical. The RNs work as a team andprovide feedback and communication within the team as well as to the administration andnursing leadership, develop recommendations to improve the process, and measure the successof this program to reduce emergency resuscitation calls. The enhanced communications amongthe empowered RNs affect the patients hospital care and decreases medical errors (Manojlovich& DeCicco, 2007).

Patient safety is a major concern for patients as well as those who work in health care and

those responsible for ensuring safe patient care. Assessment of the current perception of patientsafety culture is not as high as one would want when patients lives are at stake (Singer et al.,2003). With improved measurement tools available, healthcare organizations are beginning toassess and describe their organizations culture related to patient safety (Singer et al., 2003; Sorra& Nieva 2004a). An assessment of patient safety culture can be a useful measure for improvingpatient safety, describing the patient safety culture of an organization, raising safety awareness,and identifying opportunities for improvement (Nieva & Sorra, 2003). Despite the lack of provenbest practices, hospitals can learn from the use of a culture of patient safety survey and decidewhich scale or scales provide the best opportunity for improvement.

Significant correlations were found between the total structural empowerment score andquestions on the HSOPSC. These findings add to the current work done by Laschinger andothers who have studied structural empowerment. Structural empowerment has a link to cultureof patient safety, as the perception of structural empowerment increased so their culture ofpatient safety. This study adds to the limited literature that provides a link between structuralempowerment and culture of patient safety (Armstrong & Laschinger, 2006). It provides supportfor improvement of the nurses work environment toward one that is structurally empowering tofoster patient safety and fulfill the request made by Page in the 2004 IOMs report KeepingPatients Safe. The need for more research on the nurses work environment as it impact patientsafety.Limitations

The sample of RNs who participated in the study worked within a single, largetertiary hospital in New York, therefore limiting generalizability to all healthcare settings,more specifically across geographic borders. There also is concern about the surveyresults. Although the study was anonymous, participant concern about subjectidentification and confidentiality should be considered a limitation and may not bereflective of all RNs working within adult critical care units.Implications for Nursing Practice

Structural empowerment and the culture of patient safety are essential elements to deliverefficient, competent, and quality care. Identifying the role of the environment in promotingpatient safety can be the starting point for addressing elements that can be altered to change the

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culture of patient safety. The results should raise awareness of administrators, nurse executives,and staff about key factors in the nurses environment that promotes a safe patient careenvironment. Promoting structural empowerment structures within the workplace can influencethe culture of patient safety.Recommendations for Future Research

Additional studies assessing structural empowerment and a culture of patientsafety and background variables such as age, education, years as a nurse, years at thehospital, and certification are warranted. This study was conducted among a convenientsample of RNs. This study should be replicated in another geographic area with a similarsample or a larger sample including a broader range of healthcare professionals,including managers.Summary and Conclusion

This study adds to the extensive literature on structural empowerment within a distinctgroup of RNs. The results of this study indicate that RNs within a critical care setting perceivethemselves to be working within a structurally empowering work setting. It also adds to theliterature on the culture of patient safety within an acute care facility. This study adds to the

limited research on the relationship between structural empowerment and the culture of patientsafety among RNs. In conclusion, this study may guide nurse leaders to support a structurallyempowering work setting to achieve a culture of patient safety and reap the benefits of anempowering workforce and safe, quality patient care.


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