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This article was downloaded by: [University of Birmingham]On: 20 November 2014, At: 22:57Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
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Home Health Care Nurses' Perceptions ofEmpowermentKathleen M. Williamson MSN, PhD, RN aa College of Nursing, Florida State UniversityPublished online: 05 Dec 2007.
To cite this article: Kathleen M. Williamson MSN, PhD, RN (2007) Home Health Care Nurses'Perceptions of Empowerment, Journal of Community Health Nursing, 24:3, 133-153, DOI:10.1080/07370010701429512
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Home Health Care Nurses’ Perceptionsof Empowerment
Kathleen M. Williamson, MSN, PhD, RN
College of Nursing, Florida State University
This exploratory study involved the triangulation of qualitative (interview and observation)and quantitative methods (Psychological Empowerment Instrument). This study examinedthe individual home care nurses’ perception of empowerment and how it influences deci-sions in the home clinical setting. Fifteen nurses were self-selected to participate. All com-pleted an interview, and were observed and given Likert Instrument to complete. A frame-work analysis was performed to identify mutually exclusive and exhaustive emergentthemes and patterns within the data.
Home care nurses described that empowerment is in the interaction between nurse andpatient, and nurse and health care provider. Empowered is defined as being independent,confident, trusting, and comfortable with providing quality care. Home health care nursesbelieve that having the ability to practice collaboratively and build professional relation-ships was essential. Nurses in this study perceived empowerment as having meaning,choice, and competence in their job.
Home health care nurses provide direct clinical and preventive care to ill and/or in-jured patients in home settings. The home health nurse is constantly challenged to pro-vide quality care to consumers. Home health care nurses lead and encourage their pa-tients to be knowledgeable about their care and identify ways in which they can empowertheir patients. Empowerment is a broad concept that has had many conceptual definitionsover the years.
Empowerment is based on one’s own knowledge, skills, aptitude, and experience. Em-powerment has been linked to autonomy, job satisfaction, retention, power, and profes-sional growth and development (Greco, Laschinger, & Wong, 2006; Laschinger, 1996;Laschinger & Shamian, 1994; Klakovich, 1996; Kuokkanen, Leino-Kilpi, & Katajisto,2002, 2003; Kuokkanen & Katajisot, 2003; Matthews, Laschinger, & Johnstone, 2006;Morrison, Jones, & Fuller, 1997;). Empowerment has been identified as an abstract con-cept (Gibson, 1991; Thomas & Velthouse, 1990) and as a process (Kuokkanen &Leino-Kilpi, 2001; Zimmerman, 1995). Empowerment enables a nurse to develop psy-
JOURNAL OF COMMUNITY HEALTH NURSING, 2007, 24(3), 133–153Copyright © 2007, Lawrence Erlbaum Associates, Inc.
Correspondence should be sent to Kathleen M. Williamson, MSN, PhD, RN, Florida State University, Col-lege of Nursing, 449 Duxbury Hall, Tallahassee, FL 32306–4310. E-mail: [email protected]
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chological and physical skills that would benefit the patient and community organization(Brancato, 2003). Through the empowerment process, home health nurses can learn tomanage their professional duties and encourage patients to participate in the planningand management of their own health needs.
According to Vander Henst (1997) empowerment may be conceptualized as either aprocess or an outcome. Empowerment may lead to such outcomes as self-efficacy, per-ceived control, or improved health and well being (Vander Henst, 1997). Zimmerman(1995) described the process as one where people create or are given opportunities tocontrol their own destiny and influence the decisions that affect their lives. “Empoweredoutcomes are one consequence of empowering processes” (Zimmerman, 1995, p. 585).Sprietzer and Quinn (2001) believed that “empowerment can release the energy that cre-ates real ownership and initiative in employees” (p. 13). These authors further believedthat “empowered individuals see themselves as having freedom and discretion (self-de-termination), as having a personal connection to the organization (meaning), as confidentabout their abilities (competence) and able to make a difference in the system in whichthey are embedded (impact)” (p. 14). Spreitzer and Quinn referred to self-determinationas the individuals’ ability to choose how to do their work. Meaning is the degree to whichthe individual cares about his or her work. Competence is the individuals’ ability to betechnically competent to perform a task. Impact is the individuals’ ability to influencetheir surroundings and see that they make a difference. This study explored home healthcare nurses’ perceptions of individual empowerment as it related to the concepts of psy-chological empowerment (PE). The research questions for this study were: (a) How is PEmanifested? (b) How does PE influence home health care registered nurses? And (c)How does the PE process affect the nurse–patient relationship?
This study identified the individual factors that could have an impact on nurse empow-erment. This study also examined the individual nurse’s assessment of their own empow-erment and the factors that influence it. The main focus was on the nurse and the factorsthat influence their decisions in the home setting. Empowerment in this study did not ex-amine how the organization influences nurse empowerment but rather the nurses’percep-tion of empowerment in doing their job.
REVIEW OF LITERATURE
Empowerment
Gibson (1991), Skelton (1994), Rodwell (1996), and Ellis-Stoll and Popkess-Vawter(1998) defined empowerment as a concept from various viewpoints. Gibson defined em-powerment on a global scale and “determined that this concept has utility in nursing prac-tice” (p. 354). Skelton claimed that nurses who empower their patients must also recog-nize the political implications, as well as the meaning of the term on an individual andcommunity level. The political implications are that “nurses need to act as citizens and
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claim the right to press for rights on behalf of their patients” (p. 422). Nurses need to un-derstand that these acts may or may not be accepted. Rodwell advanced the definition ofthe concept of empowerment by defining attributes, related concepts, antecedents, andconsequences of empowerment. The outcome was a theoretical definition of empower-ment. She believed that “it is the individual who, given the power, authority, skills andwillingness to act, may choose to be empowered” (p. 309). Empowerment is a processthat engages groups or individuals to make change.
Ellis-Stoll and Popkess-Vawter (1998) also conducted a concept analysis of the termempowerment as related to the nursing literature. Their outcome was a refinement andsupport for the concept of empowerment. The patient is not the only one who acquiresknowledge in a nurse–patient relationship. The nurse gains valuable information aboutthe patient’s needs and problems. Ellis-Stoll and Popkess-Vawter discussed how behav-ior change involves gaining new knowledge, understanding, participation, and listeningby the nurse and patient. According to Ellis-Stoll and Popkess-Vawter, the ultimate goalof the empowerment process is to develop a nurse–patient relationship that encouragespatient participation.
Chandler (1992) developed an understanding of the source and the process of staffnurse empowerment and powerlessness. Her study identified that empowerment comesfrom nurses, not from someone else. Chandler reported that empowerment is derivedfrom an interaction such as those that take place between patient, family, and health careprovider. The study reported that “57% of nurses surveyed felt empowered by their inter-action with the patient and family” (p. 67). She believed that if staff nurses perceive em-powerment as enabling others, then it would be in management’s best interest to create anenvironment where nurses are empowered.
Schmieding (1993) proposed that the process of nurse empowerment occurs when thereis a linkage between “a nursing vision, structural components that involve nurse participa-tion, and the use of a process of inquiry” (p. 239). She believed that nurse empowerment isevolutionary. She believed that a vision is fundamental in all aspects of clinical and admin-istrative decision making. “It provides the framework within which the other componentsof empowerment occur” (Schmieding, 1993, p. 240). Schmeiding believed that a visionsets the direction and structural components enhance the shared vision. According toSchmieding, organizations need to identify if they are set up to empower or disempowernurses. Structural components such as the nurse CEO, the committee structure, delegationof authority, shared governance, and clinical advancement allow opportunities for nurseempowerment to develop and grow within a health care organization.
(Psychological Empowerment) PE
PE focuses on the individual’s self-efficacy and on shared power in the organizationalstructure and decision-making processes (Morrison, Jones, and Fuller, 1997). Congerand Kanungo (1988) defined PE as a motivational process. Thomas and Velthouse (1990)
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developed a broader concept and developed the Cognitive Model of Empowerment. Theyidentified empowerment as a type of motivation, referring to it as intrinsic task motiva-tion with a set of task assessments (choice, competence, impact, and meaning) that pro-duces motivation. Spreitzer (1995, 1996) further refined the work of Conger andKanungo and Thomas and Velthouse (1990). Spreitzer demonstrated that the task assess-ments (meaning, competence, self-determination, and impact) reflect an individual’s ori-entation to his or her work role.The goal of this study was to explore home health care nurses’ perceptions of empower-ment. Empowerment in this study did not examine how the organization influences nurseempowerment but rather the nurses’ perception of empowerment in doing their job.
According to Sabiston and Laschinger (1995) “Nurses who perceive themselves to beempowered are more likely to enhance client care through more effective work practices”(p. 49). The study explored home health care registered nurses’ perceptions of psycho-logical empowerment and how the empowerment process affects the nurse-patient rela-tionship.
METHODOLOGY
Design
This exploratory study involved the triangulation of qualitative (interview and observa-tion) and quantitative methods (Psychological Empowerment Instrument, PEI) to exam-ine nurse empowerment. Triangulation of data and methods allowed the researcher toovercome bias that comes from using a single method validation of conclusions andhelped to capture a more complete and contextualized portrait of the phenomenon (em-powerment) under study (Polit & Beck, 2004). The study design allowed for a compre-hensive summary and detailed description of nurse empowerment. The data were col-lected from interviews and observations of home health care registered nurses in thefield. A framework analysis was performed to identify mutually exclusive and exhaustiveemergent themes and patterns within the data. Spreitzer’s Likert scale PEI was used tocollect quantitative data on nurse empowerment (Spreitzer, 1995 & 1996).
Setting
Interviewing and observing nurses in patients’ homes, known as “in the field,” providedan opportunity to examine the nurse in the setting in which he or she worked. The advan-tage was that it allowed for a better understanding of what happened in the field. Thistechnique captured the nurses’ behaviors and actions as they naturally occurred.
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Sample
The study population consisted of a purposive sample of 15 home health care registerednurses who work for a large Mid-Atlantic private, not-for-profit home health care agency.All 15 were white women, ranging from 25–60 years old (M = 40.10 years old). Therewere two diploma nursing graduates, seven with associate degrees in nursing, and sixwith their bachelor degree in nursing. The sample’s mean years of work experience was9.65 years. Human subject’s approval was obtained prior to the start of this study.
Data Collection Methods/Instruments
Interviews, observations, and the Likert tool were chosen as the data collection methodsfor this study not only for practical reasons but to match to the research design and ques-tions. The information obtained during the one-on-one semistructured interview and di-rect observation of the nurses provided the detailed descriptions of empowerment, howthey describe empowerment in relation to the nursing care they give and how the empow-erment process impacts the nurse–patient relationship.
The interviews lasted 30–45 min and were recorded so verbatim descriptions could beanalyzed. The interview was designed with open-ended questions to encourage nurses tospeak freely about their personal experiences and perceptions of empowerment. The in-terview elicited information on how empowerment relates to the care delivery and the ef-fects of it on the nurse–patient relationship. The advantage of using the interview guidewas that it provides a framework for the topics wherein one can explore, probe, and askquestions that will provide a fuller explanation of empowerment. One recognized weak-ness in conducting interviews was the nurses’ limited time frame.
Naturalistic observations were chosen because they allowed the researcher to directlyobserve a nurse in action in the field (a patient’s home). The observations lasted 30–45min and provided the researcher with an insider’s view or emic perspective (Patton,2002). The insider’s view “means that the participant observer not only sees what is hap-pening but feels what it is like to be part of the setting” (Patton, 2002, p. 268). These ob-servations provided an opportunity to observe the nurses’ feelings, thoughts, and inten-tions as care was provided to the patient. The purpose of the observations was to describethe setting, the activities that took place, the characteristics of those who participated, andthe perceived meanings of what was observed.
Advantages of the observational method included the opportunity to see things that thenurse may not have spoken about during the interview. It allowed the researcher to expe-rience the setting in which nursing care was provided. One disadvantage of the observa-tional method was that the observation was at one point in time and could not be reflec-tive of typical nurse–patient empowerment patterns.
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Spreitzer’s (1995, 1996) 16-item PEI was used to measure the four components ofpsychological empowerment: meaning, competence, choice, and impact. Spreitzer(1995, 1996) established construct, convergent, and divergent validity. Spreitzer (1995,1996) also established internal consistency and test–retest reliability of the dimensions ofpsychological empowerment.
The interviews were conducted first, then followed by the observation of that samenurse in the field. The PEI was distributed after each interview and observation was com-pleted. The reason for this is that the interview guide probed into what things would belooked for during the observation. The triangulation of data collection methods—inter-views, observations, and the PEI—produced stronger data and provided an opportunityfor the researcher to have confidence in the data collected.
Data Analysis
Data analysis took place utilizing three categories: interview, observation, and PEI. Eachanalysis focused on the four concepts of psychological empowerment; choice,meaningfulness, competence and impact (Thomas & Velthouse, 1990). These were set apriori. The categories were established prior to the analysis based upon the CognitiveModel of Empowerment (Thomas & Velthouse, 1990). Subcategories emerged from thedata to provide a framework for the concepts and themes to describe the dimensions inmore detail as they related to nurse empowerment. Descriptive statistics were completedon the demographic data collected.
Interview. Framework analysis was conducted on the qualitative data to identifyemergent themes and patterns from the participant interviews. This approach provided asystematic process of sifting, charting, and sorting material according to the key issuesand themes that emerged (Ritchie & Spencer, 2004). The unit of analysis for the studywas a coherent statement, ranging from a few single words to one or two complete sen-tences. These statements were identified and reduced. Those with similar meaning weremerged and subcategories were identified. Formulation of definitions and categorieswere identified to isolate common themes/patterns. The use of the framework analysis al-lowed for mapping and charting of the interview data.
Observation. A separate framework analysis was conducted on the observation datato verify the interview data only and determine if the nurses said what they say they do. Theobservations were a check on the interview responses. The analysis of the observation ma-terial was carried out using qualitative framework analysis. The unit of analysis for thestudy was each verbal/nonverbal behavior, movement, action, gesture, and/or phrase.
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These statements, behaviors, actions, gestures, and phrases were identified and reduced.Those with similar meaning were merged and subcategories were identified. Formulationofdefinitionsandcategorieswere identified to isolatecommonthemes/patterns.Theuseofthe framework analysis allowed for mapping and charting of the observation data. The datacollected by the researcher from the interviews and observations was then crosschecked bya Master’s prepared nurse to provide a validity check (Patton, 2002).
PEI. The PEI was analyzed using a Microsoft Excel spreadsheet. Sixteen items on a7-point Likert scale (A. Very Strongly Disagree–G. Very Strongly Agree) were catego-rized to measure each of the four concepts of PE. Means were calculated for each concept(meaningfulness, choice, impact, and competence). The PEI was used to compare the dif-ference between what the nurses said they do and what they do, to how they perceive theirlevel of empowerment.
Methodological triangulation (Patton, 2002) was used in this study. Methods triangula-tion, using three different techniques to collect data, provided a better understanding of thephenomenon of empowerment (Polit & Beck, 2004, & Speziale & Carpenter, 2003). Trian-gulation offered an opportunity to validate the meanings in the qualitative data sets (Polit &Beck, 2004). The advantage in combining these methods—interview, observation andPEI—was that each compensated for the weaknesses of the other (Speziale & Carpenter,2003). The methods for this study were chosen to reveal different aspects of reality relatedto nurse empowerment. “Different kinds of data sets may yield different results, becausedifferent types of inquiry are sensitive to different real-world nuances” (Patton, 2002, p.248).Understandingandfinding inconsistencies in theresultsacrossdifferentkindsofdatacan be enlightening. Finding the inconsistencies should not be viewed as a weakness butrather an opportunity to delve deeper into the empowerment concept and process.
FINDINGS
Definitions of Empowerment
Nurses were asked how they define empowerment. Responses included, “Empowermentto me is when you can help the family or caregivers help the patient to be at their highestpoint of wellness in the home.” Another nurse stated, “We have the responsibility to em-power the patients.” “Empowerment is what home care is about.” The second questionwas, “If a new employee asked you if you were an empowered nurse, what would you tellthem?” All but one nurse stated they felt empowered. One nurse stated, “I have never feltempowered as a nurse; they take it away from us.” The remaining 14 nurses felt that theywere empowered. “Empowerment is the recognition of nurses and their importance inwhat they have to offer.” “All of us nurses need to stick together and empower each other.”
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“Empowerment basically is patients, caregivers, and aides feeling a connection and tofeel like they can work towards the goals and everyone is in it together as a team.”
Choice, Meaningfulness, Competence, and Impact
The use of the framework analysis allowed for mapping and charting of the interview andobservation data. The observation data was compared to the interview data. Due to a prioriconcepts, all data were searched for information that fit under the four concepts: choice,meaningfulness, competence, and impact (Thomas & Velthouse, 1990). The data weregrouped and then deduced to common themes and patterns according to the themes of PE.Following are the data extracted from the interviews and observations (Appendix A).
Table 1 displays the categories and subcategories of the concept Choice. Table 2 dis-plays the categories and subcategories of the concept Meaningfulness. Table 3 displaysthe categories and sub categories of the concept Competence. Table 4 displays the cate-gories and subcategories of the concept Impact. Table 5 displays the Observation catego-ries and subcategories.
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TABLE 1Choice Categories and Subcategories
Choice Categories Subcategory 1 Subcategory 2 Subcategory 3
Workflow Schedule Resources AccountableRelationship building Informed decisions Coordinate care CommunicationTeaching and learning Knowledge Research Nursing skillsJob satisfaction Power Control Autonomy
TABLE 2Meaningfulness Categories and Subcategories
Meaningfulness Categories Subcategory 1 Subcategory 2 Subcategory 3 Subcategory 4
Professional conduct Nursing skills Attitude Conduct CommunicationTeaching and learning Teaching Learning Instruction CommunicationCommunication Body language Verbal/nonverbal Touch N/A
TABLE 3Competence Categories and Subcategories
Competence Categories Subcategory 1 Subcategory 2 Subcategory 3 Subcategory 4
Professional development Professional Communication Continuing education N/ATeaching and learning Teaching and
learning principlesCommunicate Reinforce behaviors Process/change in
lifestyleOutcomes Issues Effects Results Consequences
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PEI
Spreitzer’s (1995, 1996) 16-item PEI was used to measure the four components of PE.This survey showed how each nurse was empowered based on the four concepts at onepoint in time (Figure 1). The person with the highest score of seven in each category canintegrate the inherent tensions of empowerment (Spreitzer & Quinn, 2001).
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TABLE 4Impact Categories and Subcategories
Impact Categories Subcategory 1 Subcategory 2 Subcategory 3
Teaching and learning Influence Effects RepercussionsOutcomes Issues Results ConsequencesDocumentation Documents/charting Care plan Nurses’ notes
TABLE 5Observation Categories and Subcategories
Observation Categories Subcategory 1 Subcategory 2 Subcategory 3
Communication Verbal/nonverbal Reinforce behaviors TouchTeaching and learning Teaching and learning principles Outcomes N/ANursing skills Assessment Equipment DocumentProfessional Attitude Conduct N/A
FIGURE 1 Home Health Care Nurse’s PEI Profile in this study.
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Overall, nurses in this study perceived their level of empowerment as strong. This wasreflected in the average empowerment score of 5.7 that they achieved on the PEI. Nursesin this study scored an average of 6.2 on meaning, 6.5 on competence, 5.7 on choice, and4.2 on impact. It must be emphasized that the scores in this study only reflect the 15nurses at one point in time and PE may fluctuate over time (Zimmerman, 1995). This in-strument provides benchmarks that can be used to monitor empowerment over time.
The combination of methods—interviews, observations, and PEI—produced data thatlinked the PE concepts of choice, meaningfulness, competence, and impact to nurse em-powerment. The multiple methods allowed for the researcher to have confidence in thedata collected.
DISCUSSION
Redefining Nurse Empowerment
The aim of this study was to explore the perceptions of empowerment by home healthcare nurses. All 15 nurses considered themselves to be empowered. One commented,“Empowerment is what home care is about.” “I think we are very much empowered.”Similar results have been obtained from previous studies of nurses employed primarily inacute care settings (Ellefsen & Hamilton, 2000; Laschinger, Almost & Tuer-Hodes,2003; Laschinger, Finegan, Shamian, & Wilk, 2001; Laschinger, Sabiston, &Laschinger, 1995; Kuokkanen, Leino-Kilpi, & Katajisto, 2003; Remmenga, 1997). Somestudies suggested that nurses did not believe they were empowered (Chandler, 1992;Haugh & Laschinger, 1996; Laschinger, 1996; Laschinger & Shamian, 1994; Lewis &Urmston, 2000; Moulton, 2000). Other studies have suggested that leaders in nursing,such as nurse managers and nurse executives, play a vital role in structuring a work envi-ronment that promotes empowerment (Greco, Laschinger, & Wong, 2006; Matthews,Laschinger, & Johnstone, 2006; Lin & Liang, 2007). According to Lin and Liang “ad-dressing the satisfaction of nurses through empowerment is essential to attract and retainnurses and improve their working environment” (p. 29).
This study adds to the body of literature on individual nurse empowerment in the homehealth care work setting. It focuses on home health care nurses’ perception of individualempowerment as it relates to providing care to patients. This was seen in the themes gen-erated under the concepts, such as relationship building, communication, and profes-sional conduct. Chandler (1992) found that “Nurses assess the patient’s needs, and thenprovide for the patients by listening to, teaching, or comforting them. The patients re-spond with increased knowledge, independence, self-care, or comfort” (p. 69).Ellis-Stoll and Popkess-Vawter’s (1998) study defined three attributes associated withempowerment. They include participation by patient and nurse, active listening, andknowledge acquisition. Our study found that nurses in home care spend a great deal of
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their time providing care to patients, listening to patients, providing the necessary teach-ing, and finding ways to comfort them. They also believed that it is the nurse’s responsi-bility to educate the patient and expand the patient’s knowledge so that they can attainwellness and maintain themselves at home. Nurses believed they were independent, con-fident, and comfortable with providing care to patients. Nurses described this by stating,“We express to doctors what we need; we speak up for the patient and for ourselves; andwe make informed decisions, coordinate care, and resolve problems.” Nurses respondedthat the knowledge gained through attending professional development seminars, contin-uing their education, and working with others to expand their knowledge was an asset.
Empowerment in this study did not examine how the organization influences nurseempowerment, but rather the nurses’ perception of empowerment in doing their job. Thenurses described their home care experiences while the researcher took notes and ob-served the nurses in action. This study, like Chandler’s (1992) and Ellis-Stoll andPopkess-Vawter’s (1998) studies, demonstrated that perceived empowerment does notcome from outside of the individuals, but rather empowerment originates from within theindividual nurse. Nurses experienced empowerment when giving care to patients. Thiswas expressed by one nurse, “Empowerment to me is when you can help the family orcaregivers help the patient be at their highest point of wellness in the home.” Nurses alsoexpressed that empowerment “is the recognition of nurses and their importance in whatthey have to offer the profession, the relevance of nursing to the medical profession as awhole, and what we can offer and accomplish.” Chandler’s study and Ellis-Stoll andPopkess-Vawter found that empowerment was derived from an interaction between nurseand patient. Nurses in this study also believe that empowerment is in the interaction be-tween nurse and patient, and nurse and health care provider.
According to Hanson, quoted in Mason, Leavitt, and Chaffee (2002), “The ability topractice collaboratively is critical to the survival of all health care providers” (p. 375).Meretoja, Eriksson, and Leino-Kilpi (2002) agreed that “collaboration and coordinationare meaningful indicators of nurse competence” (p. 100). The nurses in our study demon-strated that collaboration and communication were essential to the care of the patient.Nurses commented that “communication with doctors is essential” and “developing arapport with the patient and other health care providers provides consistency in the carethat is provided.” Nurses also affirmed that a home care nurse is independent when in thehome, but must be a team player to provide the appropriate care. They must provide goodpatient care and be competent in their nursing skills. According to Spreitzer and Quinn(2001) “Empowered people are confident about their ability to do their work well”(p. 17).
Nurses affirmed that building relationships is required in the field of home care. “Goodphysicians enable nurses—through communication, respect and trust” (Gianakos, 1997,p. 57). The nurses in this study explained that they must effectively communicate and col-laborate with physicians and other health care professionals to provide good patient care.They must also effectively communicate and collaborate with patients and their care-
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givers. “Collaboration is the process of joint decision-making among interdependent par-ties. The essence of collaboration involves working across professional boundaries”(Liedtka & Whitten, 1998, p. 185). Collaboration is a process that is the means to achiev-ing a set of valued outcomes (Liedtka & Whitten, 1998, p. 185). Nurses in home care dis-play this with their ability to work along with and collaborate with other professionals,the patient, and the patient’s family. “Physicians and nurses complement one another toachieve the common goal of patient well-being” (Gianakos, 1997, p 57). To accomplishthis, nurses in home care educate the physician on what is going on in the home, as wellas what is working and what is not working for the patient. It is known that physicianscannot know everything about their patients and rely on the home care nurses to keepthem informed and fill in the knowledge gap (Gianakos, 1997).
The nurses in this study demonstrated that it is physical, clinical, social, and emotionalknowledge that the nurses provide to the patient (Gianakos, 1997). According toGianakos, “the more knowledge shared, the more likely it is that the patient’s needs andconcerns will be met” (p. 57). This study demonstrated that the nurses are independent,competent, confident, and comfortable in identifying and providing the needed care tothe patient. This is supported by Disch and Taranto (2002), “Caregivers who demonstratemutual respect, exchange information, work well together, and help one another will bebetter able to communicate and function as members of a team with quality patient careas a common goal” (p. 339). Home health care nurses cannot work in isolation, becausecommunicating and working with others is required to provide competent care to patientsthey care for in the community. It was important to the nurses in this study to build profes-sional relationships with physicians, nurses and other health care professionals, which al-lowed them to grow as professionals, believe they were respected by their peers and pa-tients, and thus provide competent quality care.
A concept related to collaboration is trust (Disch & Taranto, 2002). According toSucci, Lee, and Alexander (1998), trust is the key element of effective work relation-ships. Trust fosters a common vision and allows health care professionals to work to-gether. Nurses in this study believed that trust was an essential element in the develop-ment of a relationship with the physician and the patient. Nurses believed that if trust wasnot present, it would be difficult to accomplish the goal of patient wellness. Covey (1989)confirmed this, “You can’t have empowerment without first having trust” (p. 64). Someobstacles that interfere are a noncompliant or nonreceptive patient, family believing theyknow what might be better for the patient, or even a doctor not listening to what a nursehad to say about the patients’ condition. Building trust was one of the strongest attributesnurses felt they must possess. “Patients trust us with their care,” “doctors listen to us,” and“we must have trust and confidence in ourselves to do a good job.”
Good communication skills are often the key to success. Ida Orlando (1961), in hernursing theory, concluded that when staff members are having difficulties with eachother, it impacts patient care. According to Orlando’s theory, professional nurses shouldbe concerned with patients who are unable to meet their own needs (Schumacher, Fisher,
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Tomey, Mills, and Sauter, 1998). Orlando’s theory places the emphasis on the relation-ship between the nurse and patient and the nurse’s ability to observe the patient’s verbaland nonverbal behavior. As home care nurses in the field, it is imperative that communi-cation be effective. Communication was extracted from the notes and placed under theconcepts meaningfulness and competence.
Autonomy was not mentioned by nurses in this study. However, nurses in home carebelieve that autonomy is inherent in their practice (Flynn & Deatrick, 2003). Nurses inhome care explained how they were independent in the care they provided to their pa-tient. Autonomy was a theme that developed and was linked to job satisfaction and theconcept of choice. The nurses in this study believed they had power, autonomy, and con-trol over the patients’ care, control over what they taught, control over their own knowl-edge base and nursing skills, and the ability to provide one-on-one good patient care.
Implications for Nursing Practice
“Empowering processes are those where people create or are given opportunities to con-trol their own destiny and influence the decisions that affect their lives” (Zimmerman,1995, p. 583). One must use caution in the interpretation of the results of this study due tothe small number of interviews and observations. However, there are implications fornursing practice. Nurses in this study perceive empowerment as having meaning, choice,and competence in their job. Empowerment is having autonomy and resources to collab-orate, trust, and communicate with health care providers and patients. Empowerment isalso the ability to provide skilled nursing care. The dimension of empowerment that wasmissing was the ability to make an impact on the organization. Nurses in this study con-firmed that trust, collaboration and communication were the most important attributes.Nurses commented that “the organization should allow more nurses to have a voice onthings that are meaningful to him/her.” As one nurse put it, “Knowledge is power. Pro-viding continuing education opportunities and the ability to sit on committees couldmake an impact on patient care and the care the nurses provide.” This was echoed bySpreitzer and Quinn (2001) and Covey (1992). “People need to learn and grow to meetnew challenges” (Spreitzer & Quinn, 2001, p. 18). “Training and development programsshould attempt to empower people to soar, to sail, to step forward bravely into the un-known, being guided more by imagination than memory, and ultimately to reach beyondtheir fears and past failures” (Covey, 1992, p. 72).
Limitations
The limitations associated with this research are the inability to generalize to a largerpopulation or work setting and the potential of creating a Hawthorne effect (Mayo, 1933,
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cited in Franke & Kaul, 1978; Patton, 2002; Polit & Beck, 2004). This purposive smallsample of participants may not represent the available population under study. On theother hand, a small sample can illuminate aspects about the phenomenon that have notbeen identified. The qualitative approaches used (interview and observation) provided anopportunity to interview and observe information rich participants who were communi-cative about empowerment.
The second limitation of this study setting was observation bias or influence. The re-searcher was only observing a nurse at one point in time and in one setting. This limita-tion occurred because the researcher, being a participant observer, may alter the way thenurse or patient reacts in the field. This may create a Hawthorne effect (Mayo, 1933, citedin Franke & Kaul, 1978; Patton, 2002; Polit & Beck, 2004). The Hawthorne effect(Mayo, 1933, cited in Franke & Kaul, 1978; Patton, 2002; Polit & Beck, 2004) could becaused by the nurse telling the researcher what they want to hear and behaving in a partic-ular manner because they are aware they are participating in a study. The Hawthorne ef-fect is hard to eliminate altogether (Patton, 2002; Polit & Beck, 2004). Strength in the re-search design was in the three-method approach used to inquire about the researchquestions.
Implications for Future Research
Nursing is experiencing a shortage of personnel that can impact the care of patients(Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Needleman, Buerhaus, Mattke, Stew-art, & Zelevinsky, 2002; Sochalski, 2001;). Home care is no exception (Flynn &Deatrick, 2003). Identifying programs and strategies that promote nurses’ empowermentare important. Findings from this study, however, provide an exploratory base that cannotbe generalized due to the small sample size. Additional studies involving larger samplesand other home care agencies would be needed to explore and identify how PE is mani-fested and how PE influences nurses and affects the nurse–patient relationship. Thisstudy was an initial effort to describe and explore the influence of psychological empow-erment over home health care nurses and the care they provide to patients.
CONCLUSIONS AND IMPLICATIONS
Empowerment enables a nurse to utilize knowledge and skills to respond to complexitiesfacing the nursing profession and its future. Home health care nurses are expected to de-sign and implement an appropriate plan of care, determine appropriate interventions,communicate with health care providers, and provide competent care in a timely manner.Home health care nurses must find ways to actively participate and become an essentialpartner in delivering quality patient care. According to Kuokkanen (2003), “through the
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empowerment process individuals, organizations and communities pursue the maximalimpact on their own lives and actual choices” (p. 62).
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APPENDIX A: DATA EXTRACTED FROM INTERVIEWS ANDOBSERVATION AND GROUPED ACCORDING TO CHOICE,
MEANINGFULNESS, COMPETENCE AND IMPACT
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