power and empowerment in nursing

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How to manage the staff duty roster

22 March, 2007

For nurses who are taking on management responsibilities, one of the most daunting tasks can betackling the dreaded off duty. Here are some tips for success

It is perhaps the biggest challenge of management. For although working out the off duty?offers a keen sense of power, the responsibility that comes with it can be more trouble than it is

worth. How you discharge that responsibility will not only determine how popular you are with

members of the team, but more importantly, how effectively your work area is resourced and

therefore the level of patient care that can be given.

The main aim in working out staffing levels is to provide consistent and effective nursing care to

those patients for whom you are responsible. In essence, staff rosters should ensure that:

The service is delivered by competent staff in the right numbers at the right times; Team members have a reasonable workload and acceptable periods of rest betweenshifts, as

outlined by the European Union Working Time Directive.

Shift-based nursing, found in both acute and community settings, poses a major challenge to a

manager who has not only to take into consideration the human resources in numbers, often

expressed as whole time equivalents (WTE), but also the staff mix, competencies and the needs

of the patient/client group, as well as other activities to be performed during the shift.

Even if you do not work in a 24/7 service, you will need to take into consideration annual leave

and requests for days off, as well as other absences.

What often increases the challenge is the use of many part-time staff. For example, five WTEstaff nurses may comprise at least seven people.

Influenced by the governments Improving Working Lives initiative, nurses are gradually beingoffered more flexibility to help with other commitments and promote a healthy work-life

balance.

We are now seeing fewer standard patterns of work, for example 10 or 12-hour shifts, and

instead find nursing staff working anything from five to 37.5 hours a week, often with half

shifts that relate to the length of a school day.

In addition, different staff do not have the same skills and competencies. Patient needs also

change, not only from day to day, but from shift to shift. There are, in addition, considerable

resource issues, both in terms of available supply and budgets.

Budget management is complex and varies between organisations, but it is common for staff to

be funded at the mid-point of their grade. If you have many senior personnel then the actual

budget needs adjusting. It is expected that, with vacancies and staff members below mid-point,

these will balance out your more expensive staff. The aim of Agenda for Change is to even out

over the whole year extra payments for unsocial hours such as bank holidays, but this system is


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still under review. Contact your areas AfC representative if you have queries relating to the new

system.

When sitting down to draw up your roster, first consider:

How many weekends do staff work per month and what are the night duty expectations?

Are routine shifts agreed for certain staff?

Next look at absences, for example annual leave, sickness and study leave, and mark them in.

Then make a list of their grades, or AfC bands, and how many shifts each staff member usually

covers. If it is your first time doing the roster, it can be very useful to refer to previous ones to

identify any pattern - as long as these worked well.

After that, identify the grade/skill mix of the shifts required. Certain shifts may require different

grades or competencies of nurses, for example assessment days, theatre days or

consultant/specialist visits.

Only then are you in a position to be able to consider requests for certain shifts or days off.

Rest assured that it will often be impossible to authorise all requests without further negotiation.

As much as you would like to please everyone, the priorities of the service must be met within

the budget.

A further challenge is covering sickness absence. Most settings will build in a percentage in

anticipating annual leave, study leave and short absences. However, for longer periods it is the

remaining team members who must be flexible in their working practices. Financial

considerations must be made before employing bank or agency staff, so you should familiarise

yourself with your organisation?s policy with regard to their usage.

Once you have finished filling in the roster, you will need to display it where all staff will see it.

Amendments may be needed due to changing circumstances relating to the clinical setting orstaff. Because you have taken time and energy to write it, you are the one who is best placed to

answer any questions.

The time and effort involved in completing the off duty will vary from person to person - but as a

novice you should expect it to take many hours. Be sure to have all the information you require,

such as requests, patterns and financial information, before you start and, where possible, arrange

in advance some undisturbed time -preferably using some of your allotted admin time.

Taking time and consideration to complete the process, maintaining good communication with

team members, will ensure you provide an effective roster that all staff can work with, and that

allows patient care to be safely delivered.

Learning the secrets of doing the off duty:

Work with another person who is practised at writing rosters;

Discuss the financial implications with the accountant/finance officer for your area;

Attend in-house training for budget management (this may be arranged with human resources

and finance departments);

Allot specific administration time to the task and do not leave it until the last minute;


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If you believe that there are fundamental shortfalls or problems with staffing levels or other

human resources issues, arrange to discuss this with your line manager, director of nursing,

human resources department or, failing that, union representative.

STAFFING IN NURSING UNITS

This page was last updated on

Nurse managers are key to revamping and

reshaping staff motivation

Renew

A staff member's lack of satisfaction with his or her work environment often

yields a lack of engagement. If neglected, this lack of engagement yieldsturnover--all the reason for nurse managers to search for ways to spark employee

motivation. Often enough, what is hindering an employee's work output are the

actions--or lack of actions--of the manager.

No matter which way you look at it, you, as the nurse manager, directly affect

staff morale. Your body language on a stress-filled day, your expression of

gratitude when an employee does more than what is asked of him or her, and your

ability to discipline a worker when he or she is not performing up to standards, all

tie into the overall work experience, good or bad. Your actions affect whether

employees feel the urge to participate in the present and hang around in the

future.

But being aware of how you conduct yourself in your facility can make all the

difference. Refer to the following tips for some guidance.

Starting the day off right. Keep in mind the first steps you take into your facility

set the tone for the rest of the day. Your arrival and the manner in which you

speak to staff in these very first moments affect the mood and performance of

those around you. If you are overtired, drink an extra cup of coffee. If you are

frustrated, do your best to conceal it because staff will see this and avoid you.

Also, instead of marching straight to you desk at the beginning of your shift, take

a quick stroll around your unit and greet people. Flash a smile, walk with poise,

and share your expectations with your staff before the day starts.

Working employees into your schedule. Studies have shown that managers

benefit by spending positive interaction time with their staff. Try to devote a part

of your time each day with each person working during your shift. Depending on

the size of your facility, this may not be realistic. If you cannot manage this,

shoot for an hour each week. This time will allow you to develop a closer bond

with staff members and also send them a message that they are an important to

you as individuals.
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The power of simple words. Building up employee motivation has much to do

with making people feel valued. Never underestimate "please" and "thank you."

Also, never miss an opportunity to tell people they are doing a great job. The

nursing profession can be emotionally-draining and challenging. Even so, these

simple, yet meaningful words can improve staff morale if said often enough, and

at the right moments.Giving feedback to staff. Information about a staff member's work performance

is an effective tool in improving it, and also in fostering engagement. People are

interested in how other people perceive them and their skills in their workplace.

Make staff aware when they do not perform up to par so that they have the

opportunity to self-correct. Set up daily or weekly meetings to check back with

them and see how they are progressing. These meetings will give you time to

express what you need from your staff, and in return, they can learn how to give

this to you.

Focus on the future. Gaining experience is one of the largest benefits of

working. Most nurses are eager to become competent in their roles so they can setout to achieve future roles. Get to know your nurses and their goals. Whether this

drive is for a pay increase, or the desire to obtain a leadership or management

position at your facility, take time to discuss this with them. Motivate staff to

explore other areas of interest and be considerate of their plans. Staff members

will be grateful for your attention to their current needs and future aspirations

2012

Motivating staff is a big part of leadership in any industry. Because of the high stress nature of staffnursing, motivation and support and proactive work environment improvement policies are very importantto retain qualified nurses. In "The Five Practices of Exemplary Leadership" Nursing," authors JamesKouzes and Barry Posner claim that "leadership is everyone's business," including CEOs, unit leaders,nurse managers and even nurses. Motivating nurses is one of the biggest challenges of nursingmanagement that registered nurse Michelle Voss says can be met by introducing interactive andproactive processes and avoiding reactive responses.

Regularly Ask for Feedback

Ask for nurses' feedback about nursing issues on a regular basis. Encourage open discussion of theireveryday challenges with patient care, hospital environment, work schedules and any other stressfulnursing issues they are experiencing. Provide a variety of avenue to express their ideas and suggestionsin a positive, proactive way, and discourage unproductive griping and complaining. Ask them what theythink about the most frequent nursing challenges they deal with at meetings, through suggestion boxes,with monthly or quarterly surveys and in performance reviews. Steer requests for feedback in a positiveway by asking about solutions, not just feelings or opinions.

Involve Nurses in Leadership

Give nurses an opportunity to demonstrate and experience leadership in their profession on a regularbasis. Schedule nurses to lead nursing or department staff meetings, research current medical topics andshare nursing experiences. Assign nurses to present small educational sessions for peer-to-peer learningabout such subjects as hospital policies, nursing procedures and patient care trends and responsibilities.


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Encourage mentoring partnerships by pairing senior nurses with new staff nurses for support, problem-solving and sharing experiences.

Set Up Mutual Understanding

Understanding the other person's point of view, experience and work processes, eases frustration anddevelops cooperation. Set up ways for staff nurses to better understand other departments such aslaboratories, pharmacies, patient intake and radiology. Encourage mutual cooperation, teamwork andproblem-solving rather than adversarial relationships. Regularly invite members of other departments tocome to nurse meetings or stop by at the beginning of shifts to introduce themselves and discuss theirdepartments. Developing a supportive and mutually cooperative relationship for nurses improves moraleand motivates nurses.

Commit to Positive Communication

Communication styles can be motivating or demotivating in any profession, and especially so in stressful,busy nursing environments. Commit to using positive communication with nurses to develop a friendly,

caring and supportive atmosphere and to provide training on positive, caring communication for staffnurses. Start nursing shifts in a positive way by greeting staff nurses at the beginning of their work day.Schedule regular one-to-one time with each nurse, whether it's daily or weekly, to listen, ask for feedback,communicate expectations, offer advice and get to know nurses and their career and work goals. Providesupport for specific problems they experience; for example, if a nurse is expressing frustration with adifficult patient, assign a more experienced nurse or a particularly caring and empathetic nurse assistantto partner with the nurse on that patient's care. Or make it a point to touch base with the nurse daily onthe difficult patient's progress for some stress relief. Good manners, friendly interactions and positivelanguage motivate nurses to model the same, provide calming interactions in stressful situations andencourage good working relationships

.

What Are the Different Types of LeadershipStyles in Nursing?

XBy Krista Sheehan , eHow Contributor


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A nurse manager will utilize a specific leadership

strategy.

Every day, nurses are responsible for the health and well-being of their patients. To ensurecontinuity of patient care, every nurse on a unit works together to achieve shared goals.This cohesive team works diligently to promote patient health, safety and recovery. Toachieve this unity, the nursing manager coordinates and supervises all interactionsbetween her team members. To do this, the nursing manager utilizes a specific nursingleadership style.

Other People Are Reading

Problems of Leadership Styles

What Is the Authoritarian Style?

Print this article

1. Transformational Leadership

o With the transformational style of nursing leadership, the focus is to unite thenursing manager and her employees to work toward a shared goal. Through
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their united goal, all members of the team work together "to purse a greatergood," according to the University of North Carolina, Charlotte. This leadershipstyles allows nurses to take an active role in evaluating, establishing andchanging policies. By carefully observing current policies and providingfeedback to their leader, nurses help promote the best actions for patient care.

As explained by NursingTimes.net, the transformational style is "more highlycorrelated with perceived group effectiveness and job satisfaction."

Transactional Leadership

o The transactional leadership ship style is relatively basic. According toNursingTimes.net, transactional leadership is "short-lived, episodic and task-based." With this style of nursing leadership, the nursing manager only interactswith her employees when something needs to be done or when something iswrong. The nursing manager will inform her employees when tasks are in needof completion. She will then retreat, allowing them to complete the tasks on their

own. If the manager see a need for changes or corrections, she will intervenewith negative feedback. Although this leadership style is not conducive tocreating a close relationship between the leader and her employees, it can beeffective during specific projects or tasks.

o

Dynamic Leadership

o The dynamic leadership style modeled its foundation after the nursing theoryset by Ida Jean Orlando, whose nursing experience is extensive. Orlando

received her Bachelor of Science degree in public health nursing and hermaster's degree in mental health nursing. She went on to become the directorof the Graduate Program in Mental Health and Yale School of Nursing. In 1961,she published a book titled "The Dynamic Nurse-Patient Relationship," in whichshe introduced her leadership theory to the world. The dynamic leadership styleuses the idea that the relationship between the leader and the nurse is ever-changing; both parties are absolutely essential to the success of the entirenursing unit. Rather than controlling her employees, the dynamic leader simplyoffers direction; this allows the nurse a significant amount of control in her work.

Read more:What Are the Different Types of Leadership Styles in Nursing? | eHow.comhttp://www.ehow.com/list_6502606_different-types-leadership-styles-nursing_.html#ixzz1wd5HZ589What leadership styles should senior nurses develop?

Leadership Styles in Nursing
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Leadership styles in nursing management play a very significant role in the management of a nursing

facility. This article throws light on management and leadership styles practiced in the nursing

profession.

A nursing leader might either be a nurse manager who is assigned the obligation of handling one unit or

a nurse executive who is responsible for the operations of all in-patient nursing units. Usually, asuccessful or effective nurse leader, typically has a repertoire of leadership skills that she employs

according to situations that are being faced.

Leadership Skills in Nursing

After a nurse graduates from a nursing school and gets her Registered Nurse (RN) license, she normally

possesses some fundamental leadership skills to apply to direct patient care. As she gets more

experienced and advances in her post, she would be required to learn more on leadership. There are

many leadership courses that are available in colleges and universities, professional education facilities,

and even large public and private hospitals. It is truly crucial for a nurse to seek advice, mentoring, and

coaching from a senior nurse leader who would render honest feedback regarding her leadership style.

Types of Leadership Styles in Nursing

Broadly speaking, there are two types of fundamental leadership styles, democratic and autocratic. A

nurse leader who is democratically inclined would engage his nurses in decision-making and let them

carry out work in an independent manner. Whereas, a directive autocrat would provide instructions

without looking for inputs and superintend his nurses in a close manner. This can also be thought of as

direct leadership and positive leadership. In direct leadership, the nurse leader would direct all the

nurses under his command as to what to do, and see to it that it gets completed accordingly. In positive

leadership, the nurse leader tries to ensure that the whole unite works as a team to get the tasks done.

In positive leadership, incentives and positivity are usually used as tools.

A nurse leader who has a considerable amount of work experience would select a leadership and

management style that would work best in any circumstance. For instance, he might play a democratic

kind of role when it is time to purchase new equipment for his nursing section. He can arrange to buy

equipment that is required by nurses, and then allow them to utilize it individually as needed. But from

the other point of view, he might act as a directive autocrat when dealing with less experienced nurses,

giving only one-sided instructions, while he closely oversees their work. Nurse leaders most importantly


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need to be very stress and tension-free while managing things, as they work in a critical life and death

situation where every moment counts, and where temperamental or emotional behavior is not

accepted. They need to be able to fully concentrate on what they do, as it may be a question of

someone's life and health.

Some Considerations of Leadership Styles in Nursing

A nurse leader might change his leadership style according to the age and expertise of nurses working

under his supervision. There can be many cases where veterans would like to share their hard-earned

expertise with new recruits who are in responsible positions, whereas younger and less-experienced

nurses might benefit from close supervision along with sufficient guidance and feedback. Nursing has

veered towards a shared model of management which involves nurses in decision-making. In this

leadership model, a nurse leader employs a democratic style of leadership, encouraging nurses toactively get involved in medical decision-making activities along with monitoring their patient results.

This is in essence about leadership styles in nursing, however, a nurse manager may change his style

according to situation and the way nurses respond to his instructions. His/her style may also change

according to situational demands of the medical facility. Effective leadership would certainly make

nursing professionals work in the best possible manner.

By Stephen Rampur29 August, 2008

Senior nurses are likely to engage in a range of leadership activities in their daily routine. Some will

naturally adopt an effective leadership style, while others may find the concept of leadership or seeing

themselves as leaders difficult to understand. Effective leadership is critical in delivering high-quality

care, ensuring patient safety and facilitating positive staff development.

Frankel, A. (2008) What leadership styles should senior nurses develop? This is an extended version of

the article published in Nursing Times; 104: 35, 23-24.

Author

Andrew Frankel, MSc, BA, PGCMS, RNM, DipN, is hospital director, Churchill Gisburn Clinic, Lancashire.


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Introduction

This article outlines the characteristics of an effective leader, the political context and various leadership

activities for senior nurses. It also discusses mentorship, different leadership models and the process of

professional socialisation.

For the purposes of this article, senior nurses are defined as practitioners with additional post-

qualification education, skills and experience who work within the nursing team providing a day-to-day,

hands-on, visible presence.

Leadership can be defined as a multifaceted process of identifying a goal or target, motivating other

people to act, and providing support and motivation to achieve mutually negotiated goals (Porter-

OGrady, 2003). In the daily life of a senior nurse, this could refer to coordinating the day/night shift and

the team of nurses and support staff on duty under the direction of that nurse. The successful operation

of the shift, staff morale and managing difficult or challenging situations depends largely on the senior

nurses leadership skills.

It is important to appreciate that leadership roles are different from management functions. In Stephen

Coveys (1999) book The Seven Habits of Highly Effective People, he quoted Peter Drucker as saying:

Management is doing things right; leadership is doing the right things. Management is efficiency in

climbing the ladder of success; leadership is about determining whether the ladder is leaning against the

right wall. This suggests that management is about tasks, whereas leadership is about perception,

judgement, skill and philosophy. We could infer from this that it is much more difficult to be an effective

leader than an effective manager.

Characteristics of an effective leader

Leaders are often described as being visionary, equipped with strategies, a plan and desire to direct

their teams and services to a future goal (Mahoney, 2001). Effective leaders are required to use

problem-solving processes, maintain group effectiveness and develop group identification. They should

also be dynamic, passionate, have a motivational influence on other people, be solution-focused and

seek to inspire others.


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Senior nurses must apply these characteristics to their work in order to win the respect and trust of

team members and lead the development of clinical practice. By demonstrating an effective leadership

style, these nurses will be in a powerful position to influence the successful development of other staff,

ensuring that professional standards are maintained and enabling the growth of competent

practitioners. In a study by Bondas (2006), leaders who were described as driving forces were admired.

They were regarded as a source for inspiration and role models for future nurse leaders.

Leadership for senior nurses is primarily about the following: making decisions; delegating

appropriately; resolving conflict; and acting with integrity. The role also involves nurturing others and

being aware of how people in the team are feeling by being emotionally in tune with staff.

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The above functions are the core elements necessary to connect leadership with the effective

development of other team members. This is largely achieved by working alongside them in a mentoringand coaching role. A good and successful leader will seek to develop other staff through their

leadership. Saarikoski and Leino-Kilpi (2002) found the one-to-one supervisory relationship was the most

important element in clinical instruction. Research also suggests that mentorship facilitates learning

opportunities, helping to supervise and assess staff in the practice setting. Terminology frequently used

to describe a mentor includes: teacher; supporter; coach; facilitator; assessor; role model; and

supervisor (Hughes, 2004; Chow and Suen, 2001).

Within my own organisation we often refer to the phrase dont just tell me - show me, which illustrates

the need for management instructions to be supported by clear leadership and supervision. It is

recommended that staff are first shown how to perform a task and then supported to complete it.

A culture based on continual learning through support and best-practice methods will empower and

motivate staff. Dynamic clinical leaders and supportive clinical environments are essential in the

development and achievement of best practice models.


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These nurses should adopt a supportive leadership style with mentorship, coaching and supervision as

core values. Constable and Russell (1986) showed that high levels of support from supervisors reduced

emotional exhaustion and buffered negative effects of the job environment. Consequently, it would be

particularly beneficial for supervisors to provide emotional support to nurses and give them adequate

feedback about performance to increase self-esteem (Bakker et al, 2000). Senior nurses should also

apply leadership skills in encouraging staff to use critical reflection to facilitate new understanding.

In the ward environment, there can be tensions between professional disciplines. Resolving these and

building effective relationships between multidisciplinary team members is a test of senior nurses

leadership abilities. With nurses becoming more autonomous decision-makers, this must inevitably lead

to revising the relationship between professional roles.

Senior nurses also have a leadership role in facilitating their organisations staff support anddevelopment programme, which should aim to reduce stress, burnout, sickness and absenteeism among

colleagues. Supervisors have a significant influence on employees personal and professional outcomes.

Bakker et al (2000) reported that senior nurses can buffer the effects of a demanding work environment

on staff nurses by thoughtfully maintaining a leadership style that supports staff needs.

A successful leader will see each person as an individual, recognising their unique set of needs, as not

everyone will perform at the same level or respond in the same way to environmental stressors or

workplace pressure. Leaders need to support staff in ways in which individuals recognise as being useful.

In the same way, staff will be motivated by different factors. Leaders must focus on the needs of

individual staff and use motivational strategies appropriate to each person and situation. They must

seek to inspire demotivated staff and maintain the motivation of those who are already motivated.

Leadership seeks to produce necessary changes in demotivated staff by developing a vision of the future

and inspiring staff to attain this. Leadership is the driving force of the work environment and directly

affects staff motivation and morale. West-Burnham (1997) argued that leaders should seek to improve

on current practice, and use their influence to achieve this. This includes working within the team to

develop goals and a feeling of shared ownership to achieve excellence in clinical practice.

Mentorship


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Different people are motivated in different ways. Therefore, leaders must use strategies that individuals

find motivating to empower them and highlight the importance of the nursing role.

One method of achieving this is through the process of structured mentorship. I believe that mentorship

should foster ongoing role development and be based on the acquisition and mastery of new skills.

Senior nurses should take time on every shift (between five and 30 minutes) to be involved in some

form of mentoring activity, which should then be recorded in staff members learning log.

The learning log is a simple, task-specific recording method used as documented evidence that

mentorship has been given on a particular area of work activity. The staff member participates in the

completion of their log, which briefly records:

The nature of the activity being coached;

Strengths and weaknesses in performing the activity;

Coaching intervention;

Future goals.

It is important that staff members do not feel micromanaged. Learning logs must be viewed as a

mentorship tool, rather than a management one. The log is merely used to remind and refresh the

mentor and staff member about what has been achieved between the last formal clinical supervision

session and the next. The learning log will be used for reflection purposes to form the basis of a more

comprehensive supervision discussion.

Leaders, in their capacity as mentors, must ensure that more junior staff have the freedom to seek

information, through an open exchange of opinions and ideas. Staff should also be given the opportunity

to show initiative, thus promoting confidence in decision-making and underpinning knowledge and

competence in their own skills. The goal of mentorship should be to create a stable and supportive

environment which encourages professional growth through effective role modelling. Murray and Main


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(2005) argued that the notion of role modelling is seen as a traditional expectation of less experienced

nurses learning from more experienced ones.

Leadership models

There are a number of useful models to help to guide senior nurses in leading other staff. The two most

common are transformational and transactional models (Bass, 1985; Burns, 1978).

The effects of transactional leadership are short-lived, episodic and task based, with the transactional

leader only intervening with negative feedback when something goes wrong. This form of leadership

would have a place where there is a specific short-term directed project or piece of work to be

completed.

In a ward, it is more desirable to identify a leadership model that offers longevity in the relationship

between senior nurses and junior colleagues. The transformational model is more complex but has a

more positive effect on communication and teambuilding than the transactional model (Thyer, 2003).

Transformational leadership shapes and alters the goals and values of other staff to achieve a collective

purpose to benefit the nursing profession and the employing organisation. Bass (1985) found that

transformational leadership factors were more highly correlated with perceived group effectiveness and

job satisfaction, and contributed more to individual performance and motivation, than transactional

leaders.

Adair (2002) proposed a different model. This is the three-circle model of strategic leadership, with the

circles being the needs of the task, the individual and the team (Fig 1).

Adair believes that knowledge or expertise alone is not enough to lead; however, without it, leadership

is impossible. Leaders should be aware of both group and individual needs, and should harmonise them

to support common goals.

Each of the three needs in the model interacts with the others. One must always be seen in relation to

the other two (Adair, 2003). This is a democratic model of leadership, in which there is consideration for

the opinions of those who have to carry out the task. Individuals and groups are involved in decision-


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making processes concerning their work. The valuing of people, their knowledge, experience and skills is

central to this model.

Leadership models are a useful tool for senior nurses and help to put the function of leadership activity

into perspective. These nurses should not be concerned about using concepts from various models and

developing an eclectic strategy. The models should be used as a framework on which to build an

effective leadership style which suits the individual leader and those whom they are leading.

Professional socialisation

Supervised learning in clinical practice fosters emotional intelligence, responsibility, motivation and a

deeper understanding of patient relationships and nurses identity and role (Allan et al, 2008).

For care standards to improve, attention must be paid to improving post-registration education and

practice development. This should include clarifying role expectation and developing a professional

identity. Professional socialisation is a learning process that takes place in a work environment, of which

junior nurses are an integral part. Effective leaders will generate opportunities which create potential

for professional self-development for junior staff. It is during this socialisation period that junior nurses

develop opinions, attitudes and beliefs about their role which form the basis of professional growth. The

role-modelling behaviour of senior nurses during this process is critical in transmitting appropriate

professional values from one generation of nurses to the next.

The role of senior nurses is dynamic and multifaceted. Nurse leaders in practice settings have unique

opportunities to influence and even create the environment in which professional nursing practice can

flourish. Marriner-Tomey (1993) suggested that, in this highly influential role, nurse leaders have a

major responsibility to change behaviour to provide an environment that supports the preparation of

competent and expert practitioners. It is part of nurse leaders role to serve as a model in providing

effective socialisation experiences that impart the appropriate values, beliefs, behaviours and skills to

staff.

Better outcomes for patient care


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practice. Journal of Nursing Management; 16: 545-555.

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Nursing; 31: 884-891.

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Staff may also feel more motivated to deliver their best performance once they feel that management

will acknowledge their hard work either by incentive schemes, such as bonuses, or by supporting nurses

by furthering their education and cross training. In this way, the empowered workplace becomes

dynamic, one in which management and staff work together to achieve the highest standards of care.

Managers can create an effective work environment by empowering nurses to utilize their professional

knowledge and assume accountability for their own actions. Management can motivate staff to become

change agents and to develop new ideas and creative ways to improve patient care.

Management, in turn, benefits from having input from staff that are most directly involved in patient

care and is able to build a more cohesive team with common goals.

This sense of motivation, shared responsibility and mutual respect may assist greatly in staff retention,

allowing management to spend more time and money on improving the quality of patient care rather

than on recruitment. Empowerment ultimately benefits the organization by increased productivity and

work effectiveness.

This differs greatly from a hierarchical system in which nurses are simply obliged to carry out the duties

assigned to them by management without really being involved in the formulation of care objectives or

unit goals.

Just as the nursing process itself involves a series of interrelated and dynamic steps, implementing

empowerment on nursing units can pose a great challenge and requires careful assessment, planning

and implementation of change at every level of the system.

Christie Hospital NHS Trust, a hospital in Manchester, England was one of the first hospitals in the

United Kingdom to implement a shared governance system based on empowering its healthcare staff in

order to improve standards of care. Christie Hospital followed a series of carefully planned steps which

resulted in the successful implementation of empowering nurses which showed the nursing process at

management level.

Their core policy highlighted the importance of allowing staff to develop professional autonomy and

encouraging staff to begin being more proactive. A steering group was formed and a vision statement


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Electricians work to provide and restore this type of power as a matter of course. Mathematicians have

a different notion of power in mind when they talk about a numeral to the second (or third) power.

Sociologists describe power as the ability to impose ones will upon others, and savvy researchers

conduct power analyses before they begin their experiments [http://en.wikipedia.org/wiki/Power].

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...there are compelling reasons to promote power in nursing...Nurses need power to be able to

influence patients, physicians, and other health care professionals.

Several definitions of power have been used in nursing. Power has been defined as having control,

influence, or domination over something or someone (Chandler, 1992). Another definition views power

as "the ability to get things done, to mobilize resources, to get and use whatever it is that a person

needs for the goals he or she is attempting to meet" (Kanter, 1993, p. 166). For Benner, power includes

caring practices by nurses which are used to empower patients (Benner, 2001). Power may also be

viewed as a positive, infinite force that helps to establish the possibility that people can free themselves

from oppression (Ryles, 1999).

Some researchers have described types of power, such as legal, coercive, remunerative, normative, and

expert power (Conger & Kanungo, 1988). Of particular interest to nursing is the concept of expert

power, which has been defined as "the ability to influence others through the possession of knowledge

or skills that are useful to others" (Kubsch, 1996, p. 198). Benner (2001) has described qualities of power

associated with caring provided by nurses such as transformative and healing power. Transformative

and healing power contribute to the power of caring, which is central to the profession of nursing

(Benner, 2001).

Power is necessary to be able to influence an individual or group. Nurses need power to be able to

influence patients, physicians, and other health care professionals, as well as each other. Powerless

nurses are ineffective nurses, and the consequences of nurses lack of power has only recently come to

light (Page, 2004). Powerless nurses are less satisfied with their jobs (Manojlovich & Laschinger, 2002),

and more susceptible to burnout and depersonalization (Leiter & Laschinger, 2006). Lack of nursing

power may also contribute to poorer patient outcomes (Manojlovich & DeCicco, in review). Studies such

as these suggest that there are compelling reasons to promote power in nursing.


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Historical Review of Nurses Power over Nursing Practice

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Although the feminist movement of the 1960s did much to bring women in other professions on an

equal footing with men, nursing's low status in the health care hierarchy remains.

A historical review of nurses power over nursing practice should include social, cultural, and educational

factors that influence nurses power over their practice. Social and cultural factors that influence nursing

power have their roots in the view of nursing as womens work (Wuest, 1994). Initially, nursing was a

domestic role women were expected to fulfill in the home (Wuest). In addition, a lot of nursing work is

done in private, behind drawn curtains (Wolf, 1989). The persistent invisibility of a lot of nursing work

decreases nursings social status and perceived value (Benner, 2001; Wolf), contributing to

powerlessness.

The fact that womens right to vote is less than 100 years old suggests oppression of women was

common in the not too distant past, and may explain in part ongoing powerlessness. Although thefeminist movement of the 1960s did much to bring women in other professions on an equal footing with

men, nursings low status in the health care hierarchy remains. Educational factors contribute to this

situation, and they are twofold. First, nursing has historically been taught in hospitals, perpetuating

nursings low status in relation to physicians and other health care providers. Since twenty-two percent

of nurses in America today are diploma graduates (Spratley et al., 2000), this educational factor may still

be contributing to nursings powerlessness. Second, the multiple entry levels into nursing practice

further dissipate whatever influence nursing may be able to generate. Nursings ongoing debate over

entry level issues may be contributing, inadvertently, to the lack of power that education should be

mitigating.

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Nursing's ongoing debate over entry level issues may be contributing, inadvertently, to the lack of power

that education should be mitigating.


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2003) and less job strain (Laschinger, Finegan, & Shamian, 2001). Alternatively, disempowerment, or the

inability to act, creates feelings of frustration and failure in staff nurses, even though they may still be

accountable (Laschinger & Havens, 1996).

Historically access to and the content of nursing education has not been fully under the control of

nurses (Rafael, 1996). Other groups continue to exert control over nurses professional lives, as

exemplified by the increasing use of unlicensed health care personnel and the medical lobby opposing

nurse practitioners as primary health care providers (Rafael). It is small wonder that nursing remains

powerless relative to other professions.

Despite empirical evidence of the positive outcomes of empowerment for nursing practice, a historical

perspective is helpful in understanding why many nurses remain disempowered. As long as nurses view

power as only having control or dominance, and as long as nursing does not control its own destiny,nurses will continue to struggle with issues of power and empowerment.

Kinds of Power over Nursing Care Needed for Nurses to Make Their Optimum Contribution

There are at least three types of power that nurses need to be able to make their optimum contribution.

The various types of power can all be categorized as stemming from nurses control in three domains:

control over the content of practice, control over the context of practice, and control over competence.

The continued lack of control over both the content and context of nursing work suggests that power

remains an elusive attribute for many nurses (Manojlovich, 2005a). In this section, power will be

discussed as it is manifested by nurses control over the content, context, and competence of nursing

practice.

Control Over the Content of Nursing Practice

Power is an attribute that nurses must cultivate in order to practice more autonomously because it is

through power that members of an occupation are able to raise their status, define their area of

expertise, and achieve and maintain autonomy and influence (Hall, 1982). One of the characteristics of a

profession is that professionals have power over the practice of their discipline which is often referred

to as professional autonomy (Laschinger, Sabiston, & Kutszcher, 1997). Autonomy represents one kind

of power nurses need, and has been defined as "the freedom to act on what one knows" (Kramer &

Schmalenberg, 1993, p. 62). Therefore a key element of empowerment is nurses control over their


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practice (Page, 2004). The ability to act according to ones knowledge and judgment is known as control

over the content of nursing practice (Laschinger et al., 1997), and is often synonymous with autonomy.

High levels of autonomy increased nurses identification with the profession in one study (Apker, Ford, &

Fox, 2003), providing recent empirical support for this supposition.

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Having control over the content of nursing practice may not be enough to provide power for nurses.

Of all decision makers in the hospital environment, only the bedside nurse, who is in closest proximity tothe patient, can fully appreciate subtle patient cues and trends as they arise and act on them to properly

care for that patient (Manojlovich, 2005a). To identify the appropriate course of action and effectively

function, professionals must have understanding and control over the entire spectrum of activities

associated with the job at hand (Manojlovich). However, it may be that nurses are frequently unable to

use their professional preparation, which focuses on autonomous practice and independent decision

making, because they are powerless relative to organizational administrators and medical staff

(Manojlovich). Having control over the content of nursing practice may not be enough to provide power

for nurses.

Control Over the Context of Nursing Practice

Besides control over the content of nursing practice, which represents one type of power, a related type

of control is known as control over the context of practice, and represents another type of power that

nurses need (Laschinger et al., 1997). Over twenty years ago it was noted that "nurses should be more

meaningfully involved in the running of hospitals" (Prescott & Dennis, 1985, p. 348). Nurses

involvement in hospital affairs is one of the hallmarks of a magnet hospital environment (McClure &

Hinshaw, 2002) but otherwise may not be apparent.

Research on magnet hospital characteristics has largely demonstrated relationships between the work

environment and patient outcomes (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Aiken, Sloane, Lake,

Sochalski, & Weber, 1999). The positive findings of the magnet hospital research may be attributed to

empowering organizational social structures, although they were not identified as such. Hospital


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characteristics which were found to attract and retain qualified staff nurses included decentralization

and participatory decision making. Although relatively little attention has been paid to how a magnet

work environment contributes to nurses sense of power (Upenieks, 2003c), repeated magnet hospital

study findings of empowering workplace structures and their relationship to improved nursing and

patient outcomes suggest that magnet hospitals attract nurses in part because of their empowering

environments.

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All of the magnet hospital studies have also consistently demonstrated positive benefits for nursing and

patients when nurses control both the content and the context of their practice.

All of the magnet hospital studies have also consistently demonstrated positive benefits for nursing and

patients when nurses control both the content and the context of their practice. In the original magnet

hospital study, nursing staff felt able to influence decisions and were in control of their own practice,

while recognizing the power of physicians and nurse leaders (McClure, Poulin, Sovie, & Wandelt, 1983).

The original magnet hospital study also recognized that the power base of staff nurses emerged from

nursing leadership, whose power came from staff, hospital administrators, and boards of trustees

(McClure et al.). A more recent study has validated the magnet hospital findings, demonstrating that

strong nursing leadership strengthens the effect of empowerment on nursing practice behaviors(Manojlovich, 2005c). Professional practice models, shared governance models, and collaborative

governance all use similar processes to increase nurses participation in decision making, thereby

increasing their control over the context of nursing practice and promoting power.

There is strong empiricaljustification for promoting nurses power through control over both the

content and context of nursing practice. In multiple studies, patient outcomes were improved when the

hospital organization was supportive of autonomous nursing practice (Aiken et al., 1999; Aiken, Clarke,

& Sloane, 2000). In these studies, autonomous nursing practice was operationalized as control over the

practice environment, decision-making ability, and collegial relationships with physicians, suggesting an

important link between power and patient outcomes.

Control Over the Competence of Nursing Practice


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A necessary precursor for both autonomy and power is competence (Kramer & Schmalenberg, 1993),

which has its foundation in educational preparation. Power is maintained through knowledge

development (Rafael, 1996), which is acquired through education and expertise. The multiple entry

levels into nursing practice, as well as the low educational level of nurses (relative to other health care

professionals) may contribute to nurses powerlessness. The statement, "Being less well-educated than

other groups within the hospital puts nursing at a serious disadvantage in organizational politics"

(Prescott & Dennis, 1985, p. 355), is no less true now than it was when written more than twenty years

ago.

Nursing expertise is a related source of power that has a transformative effect on patients lives ((Rafael,

1996). Expertise is not the same as experience, nor can expertise be acquired on nursing units with high

turnover (Benner, 2001). This suggests a complex relationship between organizational factors that

contribute to nursing turnover and the development of nursing expertise. Educational preparation and

expertise represent two additional types of power nurses need to make their optimal contribution to

patient care.

Organizational systems aimed at promoting nurses power so that they can use their professional skills

may provide an attractive and rewarding career choice for todays sophisticated students (Bednash,

2000). There may be additional benefits for hospitals that promote nursing power. Bednash (2000)

reported on a study indicating that hospitals that allowed their staff autonomy over their own practice

and active participation in decision making about patient care issues were the most successful in

recruiting and retaining nurses. In another study patient satisfaction improved when there was more

organizational control by staff nurses (Aiken et al., 1999).

The Current State of Nursing Empowerment Related to Nursing Care

Part of the difficulty many nurses have in being powerful may be due to their inability to develop the

types of power described in the previous section. Power over the content, context, and competence of

nursing practice contributes to feelings of empowerment, but control in these three domains may not

be enough. An examination of the two major areas of empowerment literature in nursing, as well as athird area not yet embraced by nursing, may help inform future directions for the development of

power and empowerment for nurses.


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Empowerment in nursing has largely been studied from two perspectives. Most nursing researchers

view empowerment as either arising from the environment (Laschinger, Finegan, Shamian, & Wilk,

2001) or developing from ones psychological state (Manojlovich, 2005b; Spreitzer, 1995).

Another contributor to nurses lack of power may be that they dont understand how power can

develop from relationships, as originally proposed by Chandler (1992). Therefore a third perspective on

empowerment, not yet embraced by nursing, is gender specific. Relational theory explains how women

engage in relationships to foster growth and nurturance (Fletcher, Jordan, & Miller, 2000). Women

develop empathy and empowerment through relationships, although the mutual processes of empathy

and empowerment are largely invisible (Fletcher et al., 2000).The answer to increasing nursing

empowerment may lie in understanding workplace sources of power, expanding the view of

empowerment to include the notion of empowerment as a motivational construct, and finally making

more explicit growth fostering relationships which also contribute to power.

Theory of Structural Empowerment

The theory of structural empowerment states that opportunity and power in organizations are essential

to empowerment, and must be available to all employees for maximal organizational effectiveness and

success. The theory of structural empowerment was developed by Kanter (1993) who saw employees

work behavior as arising from conditions and situations in the work place, and not from personal

attributes (Laschinger & Havens, 1996).

There are four structural conditions identified by Kanter (1993) as being the key contributors to

empowerment. They are: having opportunity for advancement or opportunity to be involved in activities

beyond ones job description; access to information about all facets of the organization; access to

support for ones job responsibilities and decision making; and access to resources as needed by the

employee (Kanter, 1993). Empowerment is on a continuum, because the environment will provide

relatively more or less empowerment, depending on how many of the four structures are present in the

work setting. The theory of structural empowerment places the focus of causative factors of behavior

fully on the organization, in effect maintaining that powerless individuals have not been exposedenough to the four empowering workplace structures.

In this worldview of empowerment, employees behavior is merely a response to the structural

conditions they face in the work setting. Therefore, the qualities of a job and its context evoke behaviors

from those in a job position that determine the likelihood of success (Kanter, 1993). Employees


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recognize what few empowering social structures in the environment are present, and manipulate

them, since it is only in recognition that the structures can be used.

An alternative theoretical perspective on empowerment acknowledges the fact that empowerment is

also a psychological experience. Conger and Kanungo (1988) viewed empowerment as a motivational

construct, while maintaining that it is still a personal attribute. They saw empowerment as enabling,

which "implies motivating through enhancing personal efficacy" (Conger & Kanungo, 1988, p. 473).

Spreitzer (1995) developed this version of empowerment further. According to Spreitzer, the process of

psychological empowerment is a motivational construct which manifests as a set of four cognitions that

are shaped by a work environment. The four cognitions are: meaning, competence, self-determination,

and impact (Spreitzer, 1995).

Meaning occurs when there is congruence between a nurses beliefs, values, and behaviors, and jobrequirements (Laschinger, Finegan, & Shamian, 2001). Competence refers to confidence in ones abilities

to perform the job, and is also known as self-efficacy (Laschinger, Finegan, & Shamian). Self-

determination, similar to autonomy, refers to feelings of control that are exerted over ones work.

Finally, impact is seen as a sense of being able to influence important organizational outcomes

(Laschinger, Finegan, & Shamian).

Psychological empowerment is a process because it begins with the interaction of a work environment

with ones personality characteristics; then the interaction of environment with personality shapes the

four empowerment cognitions, which in turn motivate individual behavior (Spreitzer, 1995).

Psychological empowerment reflects an active rather than a passive orientation to work, and conveys

the notion that individuals not only want to, but are able to, shape their work role and context

(Boudrias, Gaudreau, & Laschinger, 2004).

Several studies have demonstrated the effect of psychological empowerment on nursing outcomes of

burnout and nursing job satisfaction (Laschinger, Finegan, & Shamian, 2001; Laschinger, Finegan, &

Shamian & Almost, 2001). Self-efficacy for nursing practice (one of the psychological empowerment

cognitions) was recently found to contribute to professional nursing practice behaviors (Manojlovich,2005b). In fact, this study demonstrated that structural empowerment contributed to professional

practice behaviors through self efficacy, consistent with the notion that both forms of empowerment

may be necessary to sustain professional practice behaviors (Manojlovich). Research has also shown

that work environment characteristics, such as structural empowerment, contribute to psychological

empowerment in both nursing (Laschinger, Finegan, & Shamian & Almost, 2001) and non-nursing

populations (Spreitzer, 1996).


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power and empowerment in nursing

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