1. Empowerment and Job Satisfaction in Pathway to Excellence ® Hospitals 2014 SC Nursing Excellence Conference April 11, 2014 Karen Carroll, DNP, RN, NEA-BC Beaufort Memorial Hospital Beaufort, South Carolina

2. Objectives 1.Identify the level of empowerment in nurses in Pathway to Excellence Hospitals. 2.Identify the level of job satisfaction in nurses in Pathway to Excellence Hospitals 3.Discuss the relationships that exist among demographics, structural empowerment, and job satisfaction in nurses employed in Pathway to Excellence hospitals?

3. Pathway to Excellence Program ® The Pathway to Excellence Program’s 12 practice standards are based on research and expert input as to what makes a positive work environment. 1. Nurses Control the Practice of Nursing A practice environment that embraces a shared governance model is at the center of the effort to create a healthy work environment for nurses. 2. The Work Environment Is Safe and Healthy An environment where safety is paramount for both nurses and patients. Studies indicate that work environments with a culture of safety demonstrate a reduction in work-related injuries. 3. Systems Are in Place to Address Patient Care and Practice Concerns A critical issue in health care is effective communication to address practice concerns. It has been noted that silence and poor communication lead to patient safety issues and reduced job satisfaction. 4. Orientation Prepares New Nurses Studies have indicated that a solid orientation to the profession for new graduate nurses has a profound effect on nurse turnover, retention, and satisfaction.

4. 5. The Chief Nursing Officer (CNO) Is Qualified and Participates in All Levels of the Facility The CNO is the highest nursing authority within a healthcare organization. It is crucial that he or she have the proper qualifications for the role and be “at the executive table” when decisions are made about patient care delivery. 6. Professional Development Is Provided and Utilized Professional career growth is of great importance to nurses. Healthcare organizations that offer professional development opportunities to their nurses have higher RN job satisfaction and retention. 7. Competitive Wages/Salaries Are in Place Compensation has been examined as a factor influencing a nurse’s decision about where to work and where to continue to work. 8. Nurses Are Recognized for Achievements Recognition is an important factor in nurse retention and satisfaction. It lets nurses know their contributions are valued. Nurses’ achievements are known in both the internal and external environments

5. 9. A Balanced Lifestyle Is Encouraged Nurses who work in a supportive environment that encourages a healthy work–life balance are more likely to be satisfied on the job. 10. Collaborative Interdisciplinary Relationships Are Valued and Supported The literature has demonstrated that a collaborative atmosphere supports a culture of safety that results in better patient outcomes and greater job enjoyment. 11. Nurse Managers Are Competent and Accountable Strong nursing leadership has been identified as one of the top reasons nurses stay at an organization. Nurses who trust their leaders and work in an open environment that embraces patient safety are more likely to continue on the job. 12. A Quality Program and Evidence-Based Practice Are Used Evidence-based practice has been identified as an essential component of improved patient outcomes. A robust quality program, in which clinical decisions are based on solid evidence, can translate into better patient outcomes.

6. Research on Practice Environment 2007-2014 Magnet Hospital Research EBSCO cites 752 international studies/articles, (674 of those studies conducted in the United States) Texas Nurse-Friendly Hospital Research 0 studies Pathway to Excellence Hospital Research 0 studies

7. Magnet Hospital Research Professional Practice Environment Empowerment Nurse Satisfaction Nurse Hostility Healthy Work Environment Organizational Support Workload Work Engagement Working Conditions Nurse Staffing Certification Staff Development Perception of Trust Patient Quality of Care Mortality Readmission Patient experience Hospital acquired complications Missed Nursing Care Fall prevention Patient Safety Patient Safety Culture Nurse Leadership Nurse attitudes Intent to Leave Transformational leadership Intent to Stay Effect of Technology Nurse Retention CNO Leadership Burnout Nurse Manager Leadership Attributes

8. Purpose Statement The purpose of this study was to describe the relationship between demographics, structural empowerment and job satisfaction of nurses in Pathway to Excellence hospitals using Kanter’s (1993) structural empowerment theoretical model.

10. Research Questions 1.What is the level of structural empowerment in nurses in Pathway to Excellence hospitals? 2.What is the level of job satisfaction in nurses in Pathway to Excellence hospitals? 3.What relationships exist among demographics, structural empowerment, and job satisfaction in nurses employed in Pathway to Excellence hospitals?

11. Methodology Descriptive correlational design, cross sectional approach

12. Sampling Plan Non-probability convenience sampling ▫Five Pathway to Excellence designated acute care hospitals ▫East of the Mississippi River ▫Not for profit ▫Joint Commission Accredited ▫Less than 200 beds.

13. Eligibility Criteria Inclusion Criteria ▫All registered nurses who worked in any capacity in the hospital ▫Direct care ▫Non direct care ▫Full-time, part-time, per diem or float pool ▫Advanced practice nurses, contract or agency nurses Exclusion Criteria ▫Any registered nurse who was on leave from the hospital for any reason during the sampling time frame

14. Sample Size A significant direct effect of empowerment on job satisfaction (β = 0.52) was identified by Laschinger & Finegan (2005). Utilizing this statistic to estimate effect size, and assuming a significance level of 0.05 and a power of 0.80, a sample of 29 registered nurses was required. Using five hospital sites, the total required sample size was 145 nurses (29 nurses x 5 hospital sites).

15. Measures Nurse empowerment was measured using the Conditions of Work Effectiveness Questionnaire (CEWQ-II) (Laschinger, 2001) Job Satisfaction was measured using the Index of Work Satisfaction Questionnaire (IWS) (Stamps, 1997)

16. Instruments Conditions of Work Effectiveness Questionnaire II Index of Work Satisfaction (IWS) Demographic information was collected using a seven item survey

17. Protection of Human Rights Institutional Review Board approval ▫Sacred Heart University ▫Each participating hospital

18. Procedures Introductory letter to the CNO at each qualified Pathway to Excellence Hospital CNOs were asked to provide a total number of qualified RNs at their hospital. An email was sent to the CNOs at each hospital. The email with the link was sent by the CNO three times in a three week period to get maximum participation. Participation encouraged by the opportunity to win one of three $100 dollar Amazon gift cards

19. Demographics Conditions for Work Effectiveness Questionnaire (CWEQ-II) Index of Work Satisfaction (IWS)

20. Respondents 1820 total eligible nurse respondents in the 5 Pathway Hospitals 384 nurses completed the survey ▫ 21% overall response rate 64 nurses did not complete the survey 320 participants in the final analysis ▫17.5% response rate

21. CharacteristicFrequencyPercent Age Group 21-305015.6 31-406520.3 41-508927.8 51-609429.4 61-7022 6.9 Certification Certified12739.7 Not certified17454.4 Missing19 5.9 Educational Characteristics ADN11235 Diploma29 9.1 BSN14043.8 MS3811.9 PhD1 0.3

22. CharacteristicFrequencyPercent Years of RN experience 3 mos – 2 years28 8.8 3–106420 11-208526.6 21-307623.8 31-405617.5 41-6011 3.4 Years in Study Hospital < or =5 years11235 6–1010633.1 11-206119.1 21-3028 8.8 31-4012 3.8 41-601 0.3

23. CharacteristicsFrequencyPercent Employment Status Full-time26883.8 Part-time24 7.5 PRN28 8.8 Principal RN position Direct Patient Care Nurse22971.6 Nurse Mgr/Dept Head4313.4 Nurse Admin/Executive3 0.9 Quality Assurance/Review6 1.9 Advanced Practice Nurse10 3.1 Other (IT, IC, Education, etc.)29 9.1

24. Empowerment (CWEQ-II) (n = 320) Subscale Mean Standard Deviation Total Empowerment22.363.92 Opportunity4.240.70 Information3.690.94 Support3.730.89 Resources3.420.86 Formal Power3.470.94 Informal Power3.810.81

25. Index of Work Satisfaction (IWS) (n = 320) Component Component Scale Score Component Mean Score Standard Deviation ____________________________________________________________ Pay21.843.641.52 Autonomy31.145.191.16 Task Requirements24.184.031.13 Organizational Policies25.864.311.38 Professional Status35.705.950.88 Interaction32.345.390.95 Total Scale Score171.06Total Mean Score 3.88

26. Research Question 1 What is the level of structural empowerment in nurses in Pathway to Excellence hospitals? Overall nurses perceived their work environment to be at the highest end of the moderate level of empowerment (M = 22.36, SD = 3.92). Nurses thought that they had the greatest access to opportunity (M = 4.24, SD = 0.70), and the least access to resources (M = 3.42, SD = 0.86).

27. Research Question 2 What is the level of job satisfaction in nurses in Pathway to Excellence hospitals? Overall nurses perceived their jobs to be low to moderately satisfying (total score 171.06). Exception was professional status; scored in the third quartile (component scale score 35.70). Respondents were most satisfied with professional status, interaction, and autonomy. Pay received the lowest score from the respondents.

28. Research Question 3 What relationships exist among demographics, structural empowerment, and job satisfaction in RNs employed in Pathway to Excellence hospitals? Overall, total structural empowerment was significantly related with job satisfaction, (r =.72, p <.0005). Global empowerment score (GES) and total empowerment score (TES) were statistically significantly correlated (r =.82, p <.0005). No statistical differences by education level, or employment status, p >.05. There was a statistical difference by position. Direct patient care nurses scored themselves lower in empowerment and work satisfaction p <.0005.

29. Spearman’ rho: Total Empowerment Scale (TES), Index of Work Satisfaction (IWS), age, years in nursing and years in study hospital intercorrelations (n = 320) Spearman’s rhoTESIWSAgeYears in Nursing Years in Study Hospital TES p-value (2- tailed) 1.000.720*.000.052.355.089.111.048 IWS p-value (2- tailed) 1.000.099.078.156.005.118.034 Age p-value (2- tailed) 1.000.824*.000.477*.000 Years in Nursing p-value (2- tailed) 1.000.499*.000 Years in Study Hospital p-value (2- tailed) 1.000

30. Conclusions The respondents (n=320) scored in the moderate to high level of structural empowerment (22.36, SD ± 3.92).

31. CWEQ-IICurrent Study 2013 Donahue 2005 Laschinger et al 2001 Upenieks 2001 Upenieks 2001 Pathway toCommunityUrbanMagnetnon-Magnet ExcellenceHospitalHospitals (all nurses) (staff nurses) n= 320n= 187n= 404n= 144n= 161 MMMMM __________________________________________________________________________________ _ Opportunity4.243.803.854.043.88 Information3.693.263.463.002.83 Support3.733.202.943.402.85 Resources3.42 2.643.022.37

32. Conclusions Index of Work Satisfaction scale score 171.06. The findings confirmed that professional status, interaction and autonomy received the highest mean score in assessing the nurses’ current level of job satisfaction. The job satisfaction components that received lower mean scores from the respondents were task requirements, organizational policies and pay. Overall, total structural empowerment was significantly related with work satisfaction (r =.72, p <.0005). Direct patient care nurses scored themselves lower in empowerment and work satisfaction p <.0005.

33. Conclusions There were no statistical differences by education level, or employment status, p >.05. Neither the TES nor the IWS were correlated with age, years in nursing, or years at the study hospitals indicating that extrinsic factors were responsible for the overall empowerment and job satisfaction scores

34. Conclusions Theoretical framework Results supported Kanter’s (1993) theory of structural empowerment. Theory states that access to information, support and resources, necessary for work, had a positive effect on employees.

35. Limitations Results not generalizable to nurses in all Pathway to Excellence Hospitals Results may not be indicative of the entire population. The response rate was low at 17.5% Completion of the survey was voluntary.

36. Implications Practice Strategies that promote and foster nurse empowerment should be developed and encouraged. Nursing administrators can use this research to examine their workplaces for structural factors that act as barriers to staff nurses’ access to empowerment structures.

37. Implications Nursing Education Educate nurses about empowerment and the benefits of a positive practice environment Through education and staff development, nurses will learn of ways that they can participate in decision making and impact the professional environment in which they practice

38. Implications Policy This study suggests that nurses in Pathway to Excellence hospitals might also experience higher levels of empowerment and job satisfaction. As value based purchasing becomes the benchmark for reimbursement to hospitals, the value of a stable, competent and satisfied nursing workforce needs to be evaluated. Creating and maintaining work environments where nurses excel and flourish in their practice is cost savings and value added.

39. Recommendations Further research is needed to validate this work in Pathway to Excellence hospitals. Every effort must be made to create work environments that attract and retain highly qualified professional nurses.

40. Karen Carroll, DNP, RN, NEA-BC kcarroll@bmhsc.org 843-522-7650