By Judy A. Tigert, ACNP, MScN CCN(C),Renal Care, London Health Sciences Centre andHeather K. Spence Laschinger, PhD, Professor andAssociate Director Nursing Research, School of NursingHealth Sciences, Faculty of Health Sciences,University of Western Ontario, London, Ontario.

AbstractThe purpose of this study was to test Kanters Theory (1977,1993) of Structural Power in Organizations in a sample ofCanadian critical care nurses. A secondary analysis of datafrom a larger descriptive correlational survey design was usedto examine the relationships between perceived empowerment,perceived magnet hospital traits and critical care nursesmental health (n = 75). The instruments in this study includedthe Conditions for Work Effectiveness Questionnaire II, theJob Activities Scale II, the Organizational Relationship ScaleII, the Nurses Work Index-Revised, the Emotional ExhaustionSubscale, and the State of Mind Subscale.

Empowerment was significantly and positively related toperceptions of magnet hospital traits (r = .49, p = 0.001). Thecombination of empowerment and magnet hospital traitsexplained a significant amount of the variance in mentalhealth indicators: burn-out (19%) and state of mind (12%).

Background and rationaleThe Canadian NursesAssociation predicts that Canada couldsuffer a shortage of 78,000 nurses by the year 2011 (Fletcher,2002). The work environment is one factor contributing to theshortage. Sustaining nurses in specialty areas such as criticalcare will be particularly challenging. Intensive care units arefast-paced work environments with critically ill patients whoare attached to invasive technology while nurses tend to theirneeds, monitor progress, troubleshoot alarms and comfortgrief-stricken families. These environments are stressful fornurses (Bailey, Steffen & Grout, 1980). Measures must betaken to support the health of critical care nurses so they willchoose to remain in the profession and continue to providequality care for the critically ill.

Studies on the effects of the work environment on nursesattitudes and behaviours have consistently shown that jobsatisfaction and turnover are related to autonomy, job strain,and decisional involvement in the workplace (Havens &Laschinger, 1997; Sabiston & Laschinger, 1995). Magnethospital work environments have been found to support theprofessional practice of nursing and decrease nurse turnoverand burn-out (Aiken, Smith, & Lake, 1994).

One theory used to study the nursing work environment isKanters Theory of Structural Power in Organizations (Kanter,

1977, 1993). Kanter contends that structural conditions in theworkplace that are empowering influence the employeesability to accomplish work in a meaningful way which, in turn,leads to feelings of job satisfaction and work effectiveness. It isreasonable to expect that these empowering work environmentswould support the professional practice behaviours thatcharacterize practice in magnet hospitals (nurse autonomy,control over the practice setting and collaboration withphysicians). Moreover, both workplace empowerment andmagnet hospital characteristics have been linked to nursesemotional health in the workplace (Laschinger & Havens,1997; Aiken, Sloane & Klochinski, 1997).

The purpose of this study was to test a model derived fromKanters theory linking critical care nurses perceptions ofworkplace empowerment, perceptions of the presence ofmagnet hospital traits in their work setting, to their perceivedmental health.

Theoretical frameworkKanters Theory of Structural PowerKanter (1977, 1993) proposes that employee work effectivenessis largely related to structural or situational aspects of theorganization. Kanter identified three empowerment structures inorganizations that have a personal impact on employeebehaviour and attitudes: (a) the structure of power, (b) thestructure of opportunity, and (c) proportion structures (socialcomposition of peer clusters). These structures in the workenvironment affect employee work behaviour/attitudes morethan employee personality traits. Access to these structures isinfluenced by the degree of formal and informal power held byemployees. Formal power is found in jobs that are visible,central to the purpose of the organization and that allow fordiscretion in decision-making. Informal power systems(alliances) are relationships with supervisors, peers andsubordinates that enable (powerful) individuals to get thingsdone. The three sources of power are: (a) resources, (b)information, and (c) support. Information refers to the data,technical knowledge and expertise required to functioneffectively and carry out the tasks required to perform ones job.Resources refer to the money, materials, supplies and equipmentrequired to accomplish the goals at work. Support is thefeedback and guidance received from the supervisor, peers andsubordinates. Opportunity is the potential of advancing tochallenging positions or roles within the organization and theextent to which the job allows the employee to gain skill whilebeing rewarded and recognized. Access to empowermentstructures results in increased motivation, autonomy, employeedecisional involvement, organizational commitment and jobsatisfaction. Consequently, employees become more productiveand effective in meeting organizational goals.

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Critical care nurses perceptions ofworkplace empowerment, magnethospital traits and mental health

Review of the literatureNumerous nursing studies support Kanters contention thatworkplace empowerment is associated with employeeinvolvement in decisions related to the content (autonomy)and context of practice (participation in managementdecision-making). Laschinger, Sabiston and Kutszcher(1997) found that autonomy was significantly explained byformal and informal power and access to workplaceempowerment structures. Nurses perceptions ofempowerment were also strongly related to theirperceptions of participative management. Several otherstudies have linked empowerment to staff nurse decisionalinvolvement (Havens & Laschinger, 1997; Huffman 1995;Laschinger & Havens 1997). Almost and Laschinger(2002) found a significant positive relationship betweennurse practitioners perceptions of workplaceempowerment and collaboration with physicians. Thesestudies suggest that empowerment may be an importantdeterminant of magnet hospital characteristics (autonomy,control over the practice setting, and collaboration withphysicians). Empowerment has also been negativelyassociated with job stress and burn-out (Hatcher &Laschinger, 1996; Laschinger & Havens, 1997;Laschinger, Wong, McMahon & Kaufman, 1999;Laschinger, Finegan, Shamian & Wilk, 2001).

In 1982, theAmericanAcademy of Nursing (AAN) recognizedhospitals that were supportive of the professional practice ofnursing and had no difficulties recruiting and retaining nurses.These hospitals became known as magnet hospitalscharacterized by work environments that fostered high levelsof nurse autonomy, nurse control over practice andcollaborative nurse-physician relationships (Kramer &Schmalenberg, 1988; McClure, Poulin, Sovie & Wandelt,1982). Magnet hospital designation continues to be a valuedaccreditation in the United States today.

Burn-out is a frequently studied indicator of nurses mentalhealth. Work stress has frequently been associated with burn-out in nursing staff (McCranie, Lambert & Lambert, 1987;Robinson, Roth, Keim, Levenson, Flentje & Bashor, 1991).Bailey, Steffen and Grout (1980) identified sources of stress inthe critical care setting. The top ranked job-stressors were: (a)interpersonal conflict, (b) management of the unit, (c) natureof direct patient care, (d) inadequate knowledge and skills, (e)physical work environment, (f) life events, and (g) lack ofadministrative rewards.

Gentry, Foster and Froehling (1972) found that critical carenurses demonstrated significantly more depression,resentment, irritability and verbal aggression than did non-critical care nurses. Lewis and Robinson (1992) found thatcritical care nurse use of maladaptive coping measures (drugsto relax, absenteeism, alcohol, overeating, smoking andcaffeine) were related to perceived stressors at work. Iskra-Golec, Folkard, Marek and Noworol (1996) found that ICUnurses working 12-hour shifts experienced significantly moreburn-out, chronic fatigue, cognitive anxiety, and general sleepdisturbances than did nurses working eight-hour shifts.

Hypothesis

High levels of workplace empowerment and magnet hospitaltraits in the work environment are positively related to criticalcare nurses mental health.

MethodsDesign and sampleThe data for this study were drawn from the second wave ofa longitudinal study of nurses in Ontario, Canada (1998 and2001). This study, a correlational survey design, examined therelationships between critical care nurses perceptions ofworkplace empowerment, magnet hospital traits in theworkplace, and nurse mental health. The original data setconsisted of 239 nurses who worked in Ontario teachinghospitals. The nurses names were randomly selected from theCollege of Nurses of Ontario (CNO). The overall return ratefor the second wave of data collection (2001) was 69.8 percent. There were no significant differences with regard to thedistribution of demographic characteristics or major studyvariables between respondents in the first and second wave ofthe study.

A subsample of 75 critical care nurses provided 80 per centpower to detect a medium effect size, based on Cohens (1988)conventions for regression of two independent variables.

InstrumentsResearch instruments are frequently evaluated by theirconstruct validity and internal consistency (reliability). Awidely used index of reliability is the Cronbachs reliabilitycoefficient. The normal range for the Cronbachs reliabilitycoefficient is between 0.00 and 1.00, with higher valuesrepresenting greater reliability (Polit & Hungler, 1999).

The Conditions for Work Effectiveness Questionnaire II(CWEQ-II), The Job Activities Scale II (JAS-II), and theOrganizational Relationship Scale II (ORS-II) (Laschinger,Finegan, Shamian &Wilk, 2001) measured empowerment. TheCWEQ-II has four subscales that measure perceived access toempowerment structures: (a) opportunity, (b) information, (c)support, and (d) resources. Items are rated on a five-point Likertscale. Subscale mean scores are obtained by summing andaveraging items (range one to five) with high scores indicatinghigher levels of perceived access to empowerment structures.

The construct validity of the CWEQ-II has been substantiatedby Laschinger, Finegan, Shamian, and Wilk (2000) in aconfirmatory factor analysis. The Cronbach reliabilitycoefficients for the CWEQ-II were: 0.81 (total), 0.82(opportunity), 0.91 (information), 0.81 (support) and 0.81(resources).

The JobActivities Scale (JAS-II), a three-item scale, measuredcritical care nurses perceptions of formal power, that isperceptions of discretion, visibility and recognition within thework environment. The Cronbachs reliability coefficient forthe measurement of formal power (JAS II) was 0.75. TheORS-II, a four-item scale, was used to measure perceptions ofinformal power within the work environment. The Cronbachsreliability coefficient for the ORS II was 0.65.

The NWI-R, a revision of the original Nursing Work Index(NWI), was used to measure magnet hospital traits (Aiken &

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Patrician, 2000). The three NWI-R subscales used mostfrequently in magnet hospital research (autonomy, control overpractice, and nurse-physician relationships) were also used inthis study. Items are rated on a four-point Likert scale.Subscale mean scores were obtained by summing andaveraging items with high scores indicating higher levels ofautonomy, control over the practice environment andcollaboration with physicians. Cronbachs reliabilitycoefficients for the NWI-R subscales were: 0.86 (total), 0.71(autonomy), 0.76 (control), and 0.88 (collaboration).

Mental health was measured using the five-item State of Mindsubscale (SOM) of the Pressure Management Indicator (PMI)(Williams & Cooper, 1998) and by the six-item EmotionalExhaustion (EE) subscale of the Maslach Burn-out Inventory(MBI) (Maslach & Jackson, 1981). State of Mind was rated ona six-point Likert scale (range one to 6). The Cronbachsreliability coefficient for the SOM subscale was 0.78.Emotional exhaustion was rated on a seven-point Likert scale(range zero to six). The Cronbachs reliability coefficient forthe EE subscale was 0.89.

A brief questionnaire examined the demographiccharacteristics of the participants (gender, age, years of workexperience, work status, years on unit, dependents under fiveyears of age, education level, overtime worked, occasions ofillness, and hospital type).

Data analysis and descriptive resultsDescriptive and inferential statistics were computed usingSPSS Version 10 (SPSS, 2001). Demographic characteristicsof the participants are displayed in Table One. Reliabilityanalyses were conducted on all subscales used in the study.The means and the standard deviations for the major study

variables are displayed in Table Two. There were nosignificant relationships found between the major studyvariables and demographic characteristics of the participants.

Tests of the hypothesisAs predicted, the combined effect of workplace empowermentand magnet hospital traits was found to be significantly relatedto critical care nurses perceptions of mental health. Nineteenper cent of the variance in emotional exhaustion (EE) incritical care nurses was explained by empowerment andperceptions of magnet hospital traits (R2 = .19, F (2, 71) =8.06, p = .001). However, only empowerment was a significantindependent predictor of EE (B = 0.33, t = - 2.7, p = .01). Thisfinding is consistent with a study that linked empowerment toburn-out (Hatcher & Laschinger, 1996). Similarly, 12 per centof the variance in state of mind (SOM) was explained by thecombined effect of empowerment and perceptions of magnethospital traits (R2 = .12, F (2, 70) = 4.57, p = .02). Althoughperception of magnet hospital traits was a significant predictorof SOM (B = -.31, t = 2.4, p = .02), empowerment was not (B= .06, t = 0.48, p = .63). The relationship between SOM andmagnet hospital traits has not been reported in previousliterature. These findings suggest that nurses are more likely toexperience less emotional exhaustion and higher levels ofmental health in hospitals that foster both empowerment andprofessional nursing practice (magnet hospital traits).

DiscussionThe findings of this study lend further support to Kanterspropositions (1977, 1993) that access to empowermentstructures is associated with positive employee outcomes, inthis case, employee mental health. Consistent with theoreticalpredictions, higher levels of empowerment were associated

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Table One: Sample descriptive statistics

StandardN Minimum Maximum Mean Deviation

Age (years) 71 32.00 61.00 43.9437 5.83313Years experience in nursing 75 2.00 38.00 19.6467 7.16399Years on present unit 74 1.00 35.00 11.6149 6.26282

Education Frequency Per cent Valid Per cent Cumulative Per centHospital diploma 12 16.0 16.0 16.0Community college diploma 45 60.0 60.0 76.0BScN 11 14.7 14.7 90.7MscN 1 1.3 1.3 92.0Other 6 8.0 8.0 100.0Total 75 1.00 100.0

Gender Frequency Per cent Valid Per cent Cumulative Per centMale 41 54.7 54.7 54.7Female 34 45.3 45.3 100.0Total 75 100.0 100.0

Marital Status Frequency Per cent Valid Per cent Cumulative Per centSingle 13 17.3 17.3 17.3.Married/cohabiting 57 76.0 76.0 93.3Separated/divorced 4 5.3 5.3 98.7Widowed 1 1.3 1.3 100.0Total 75 100.0 100.0

with greater autonomy, control over the practice environmentand nurse-physician collaboration in critical care settings. Thisstudy also provides empirical evidence for the link betweenKanters concept of empowerment and magnet hospital traitsin critical care settings.

Critical care nurses did not perceive themselves to be highlyempowered. These results are consistent with the findings ofBaguley (1999). In this study of Canadian critical care nurses,levels of autonomy, collaborative relations with physicians andcontrol over the practice setting were lower than those foundin American magnet hospitals (Aiken, Havens & Sloane,2000). This suggests that there is room for improvement inCanadian nursing work environments. The moderately highlevels of nurse-physician collaboration reported by criticalcare nurses were similar to those in a study of Canadian NursePractitioners (Almost & Laschinger, 2002). This is notsurprising given that both groups have advanced skills andwork in close proximity with physicians.

Both empowerment and perceptions of magnet hospital traitswere significantly related to mental health. Empowerment wasa stronger predictor of emotional exhaustion while perceivedmagnet hospital traits predicted state of mind more strongly.These findings suggest that both empowerment and perceptionsof magnet hospital traits are predictive of positive employeemental health, although each affects different domains ofmental health. These findings are consistent with previousresearch (Laschinger, Finegan, Shamian, & Wilk, 2001;Laschinger & Havens, 1997) and further support Kanters(1977, 1993) contention that access to empowerment structuresin the workplace can decrease job stress and positivelyinfluence employee mental health. The results of this study willbe discussed as they apply to critical care nurses and managers.

Implications for critical care nursesCritical care nurses must proactively examine their workenvironment, assess the health risk, and collaborate with theirmanagers and colleagues to create environments conducive tohealthy working conditions. Kanters (1997, 1993) theory

provides strategies for creating such environments. This can beaccomplished by active participation of nurses in committeesthat influence nursing practice and by working collaborativelywith physicians and peers. It would be advantageous forcritical care nurses to become familiar with guidelinesadvocated by the Magnet Services Recognition Program(1999) by participating in professional organizations andconference planning committees that could arrange conferencespeakers from magnet hospital organizations.

Implications for critical care nurse managersIn todays fiscally constrained health care setting, critical carenurse managers are challenged to contain costs, reduceabsenteeism, minimize adverse outcomes and enhance patientsatisfaction. The nurse manager today must be cognizant ofevidence-based predictors of organizational effectiveness suchas work empowerment. With the growing body of evidence tosupport Kanters theory, it behooves the nurse manager tobecome very familiar with the strategies implied by the theory.The nurse manager must strive to empower the nursing staffthrough provision of information, support, resources andopportunities. As evidenced by this study, nurse managers whoincorporate these aspects into nursing work environments arelikely to create work environments where nurse autonomyexists, where nurses have control over the practice setting, andwhere nurse-physician collaboration thrives.

The Magnet Services Recognition Program (1999) is alsoessential for nurse managers. It is with this practical knowledgethat managers can develop the processes and systems in theirown organizations that will enhance nurse autonomy, controlover practice and collaborative nurse-physician relationships.The findings of this study support the importance of magnethospital-like working conditions with respect to nurses healthand suggest that there is work to be done to improve criticalcare work environments in Ontario. Given the impendingnursing shortage in Canada, nurse administrators must makeevery effort to ensure that the work environment supportsnurses ability to practise according to professional standards,thereby reducing stress and increasing satisfaction.

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Table Two: Observed means and standard deviations for instrument scales and subscales

Instrument n Score Range Mean SD

Overall Empowerment (Total CWEQ II)Sum of 6 Empowerment Scales 75 6 - 30 17.66 3.24Subscales:

Opportunity 75 1 - 5 3.90 0.73Information 75 1 - 5 2.78 0.93Support 75 1 - 5 2.54 0.88Resources 75 1 - 5 2.74 0.84Formal Power 75 1 - 5 2.30 0.86Informal Power 75 1 - 5 3.4 0.69

Nursing Work Index-Revised Total Score 74 1 - 4 2.63 0.48Autonomy 74 1 - 4 2.47 0.56Control Over Practice 74 1 - 4 2.52 0.57Collaboration with Physicians 74 1 - 4 2.90 0.65

Mental Health IndicatorsEmotional Exhaustion Subscale 75 0 - 6 3.10 1.29State of Mind Subscale 74 1 - 6 4.42 0.91

LimitationsThe limitations of this study are related to both the design andthe methods used. Due to the correlational design of the study,causal relationships cannot be inferred. Response bias isalways a concern with the use of self-report questionnaires(Polit & Hungler, 1999). Critical care nurses who responded tothe survey may have been intrinsically more empowered andmay have experienced better levels of health than those whodid not respond. Another limitation of the study is thesampling process used to acquire subjects. Critical care nursesmay have been missing from the CNO registry list, becausethey may have refused to allow the CNO to release their namesfor research purposes. The fact that the sample was selected inthe province of Ontario prevents generalization to otherCanadian nurses.

AcknowledgementThe authors would like to acknowledge CACCN for providingfunding for this research project.

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