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Workplaceempowermentandnurses'jobsatisfaction:Asystematicliteraturereview

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Workplace empowerment and nurses’ job satisfaction: asystematic literature review

GIANCARLO CICOLINI RN , M SN , P h D 1 , DANIA COMPARCINI RN , M SN 2 and VALENTINASIMONETTI RN , M SN 2

1Nurse Director and 2PhD Student, Center of Excellence on Aging, Clinical Research Center CRC-CeSI, ‘G.d’Annunzio’ University, Chieti Scalo, Italy

Correspondence

Giancarlo Cicolini

Center of Excellence on Aging,

Clinical Research Center CRC-

CeSI

University of ‘G. d’Annunzio’

Chieti - Via dei Vestini 31

66013 Chieti Scalo

Italy

E-mail: g.cicolini@unich.it

CICOLINI G., COMPARCINI D. & SIMONETTI V. (2013) Journal of Nursing ManagementWorkplace empowerment and nurses’ job satisfaction: a systematic

literature review

Aims This systematic review aimed to synthesize and analyse the studies thatexamined the relationship between nurse empowerment and job satisfaction in

the nursing work environment.

Background Job dissatisfaction in the nursing work environment is the primarycause of nursing turnover. Job satisfaction has been linked to a high level of

empowerment in nurses.

Evaluation We reviewed 596 articles, written in English, that examined therelationship between structural empowerment, psychological empowerment and

nurses’ job satisfaction. Twelve articles were included in the final analysis.

Key issue A significant positive relation was found between empowerment andnurses’ job satisfaction. Structural empowerment and psychological empowerment

affect job satisfaction differently.

Conclusion A satisfying work environment for nurses is related to structural andpsychological empowerment in the workplace. Structural empowerment is an

antecedent of psychological empowerment and this relationship culminates in

positive retention outcomes such as job satisfaction.Implication for nursing management This review could be useful for guiding

leaders’ strategies to develop and maintain an empowering work environment

that enhances job satisfaction. This could lead to nurse retention and positiveorganisational and patient outcomes.

Keywords: job satisfaction, psychological empowerment, review, structural

empowerment, workplace

Accepted for publication: 18 September 2012

Background

Nursing shortage is increasing because nurses are

leaving the profession, particularly as a result of diffi-

cult working conditions (Buerhaus et al. 2000, 2006)

and unsatisfying workplaces (Hayes et al. 2006, Pur-

dy et al. 2010). A recent study showed that the fac-

tors causing this desertion could be: a high nurse

turnover (Hauck et al. 2011), heavy workloads and

lack of development opportunities (Laschinger et al.

2009a).

Job satisfaction is defined as the degree of affect

toward a job and its main components (Adams &

Bond 2000) and can be considered to be a positive

concept describing work behaviours in work settings

(Utriainen & Kyngas 2009). Nurses’ job satisfaction is

DOI: 10.1111/jonm.12028

ª 2013 Blackwell Publishing Ltd 1

Journal of Nursing Management, 2013

related to professional, personal and organisational

variables (Lu et al. 2005) and is influenced by both

nurses’ working environment and nurses’ personal

characteristics (Adams & Bond 2000).

Nurse managers have to maintain high-quality stan-

dards of care and job satisfaction among nurses, often

with a lack of human and financial resources (Lee &

Cummings 2008). Transformational leadership style

is based on principles of empowerment, and it is able to

support these organisational conditions. To date, trans-

formational leadership is the most effective model of

management in the healthcare system for developing a

positive relationship between managers and nursing

staff, to promote nurse satisfaction and organisational

commitment (Ellefsen & Hamilton 2000, Falk-Rafael

2001, Laschinger et al. 2001a).

Workplace structures can support healthier nurses,

reduce stress and increase commitment and job

satisfaction, and also improve organisational and

patient outcomes (Wagner et al. 2010). Nurse leaders

need to carry out evidence-based approaches for

empowering work environments that ensure satisfac-

tion, which in turn could ensure high quality care

(Laschinger 2008).

The term ‘empowerment’ in the organisational con-

text is used in two different perspectives: psychological

empowerment and structural empowerment. Structural

empowerment refers to the application of management

(Kanter 1977) and occurs when employees have access

to empowerment structures (Laschinger et al. 2004).

The psychological empowerment (Spreitzer 1995) deals

with ways in which these applications are experienced

and understood by workers (Cavus & Demir 2010)

and occurs when there is a sense of motivation in rela-

tion to the workplace environment (Manojlovich &

Laschinger 2007).

Based on previous studies on psychological empow-

erment (Conger & Kanungo 1988, Thomas & Velt-

house 1990), Spreitzer (1995, 1996) developed a

multidimensional instrument to measure the psycho-

logical empowerment in the workplace through four

cognitive dimensions reflecting why employees feel

empowered.

The first cognitive dimension is meaning, referring

to how much employees feel that their work is impor-

tant in relation to the congruence between workplace

requirements and one’s own beliefs, values and behav-

iours. The second is competence, referring to the level

of one’s capability to perform job requirements

successfully. The third is self-determination, referring

to the sense of autonomy that people have towards

their own work. The fourth dimension is impact,

referring to the level to which people feel that they are

able to have an influence on the workplace.

Kanter (1977) defined an empowering work environ-

ment as a workplace in which employees have access to

the four empowerment structures. The first structure is

information, referring to the data, technical knowledge

and expertise that are necessary effectively to fulfil

someone’s professional requirements (Laschinger &

Havens 1996). The second is resources, referring to

material, money, time, requirement and equipment

needed to accomplish the organisational goals. The

third is support, referring to feedback, leadership and

guidance received from superiors, peer and subordi-

nates. The last is opportunities referring to autonomy,

self-determination, a feeling of challenge and the oppor-

tunity to learn and grow. The access to these structures

is facilitated by two specific sources of power in organi-

sations: formal power (specific job characteristics) and

informal power (interpersonal relationships with supe-

riors, peers and subordinates) (Miller et al. 2000).

Chandler (1986) was the first to test Kanter’s theory

of organisational empowerment in nursing settings.

Based on Kanter’s (1977) theory and Chandler’s

(1986) work, the University of Western Ontario

Workplace Empowerment Research Programme has

been created. To date, the main studies testing Kan-

ter’s model of empowerment in health care settings

have been conducted by Laschinger and colleagues

(Laschinger and others, 2000–2011). Further research

(Laschinger et al. 2001a,c,d) has been carried out to

expand Kanter’s model with the addition of Spreitzer’s

(1995) model of psychological empowerment.

In the past two decades, researchers have integrated

both the structural and the psychological perspectives

of empowerment (Spreitzer 2007) in order to under-

stand empowerment at work.

Both perspectives are correlated with measurable

positive workplace outcomes, particularly with job

satisfaction (Stewart et al. 2010, Wagner et al. 2010),

which is essential to support changes at all levels of

the organisation and to achieve long-term outcomes

for managers, staff and patients (Laschinger & Havens

1996, Manojlovich & Laschinger 2002). Nurse manag-

ers have to incorporate empowerment techniques

into management strategies (Chang et al. 2011) to

increase nurse satisfaction within the work environment

(Upenieks 2003).

Significance

Many factors contribute to the current nursing short-

age, high nurse turnover is considered one of the main

ª 2013 Blackwell Publishing Ltd

2 Journal of Nursing Management

G. Cicolini et al.

contributors (Hauck et al. 2011) while job dissatisfac-

tion is the primary cause of nursing turnover (Lautizi

et al. 2009).

Nursing retention is related to workplace variables

and to job satisfaction (Coomber & Barriball 2007).

Furthermore, nurses’ perceptions of workplace empow-

erment is related to intent to stay, independently of

individual factors (Nedd 2006).

Recent studies show that workplace empowerment

has a strong relationship with nurse retention and an

important impact on factors related to recruitment,

particularly on job satisfaction (Laschinger et al.

2001a, Faulkner & Laschinger 2008) and commit-

ment (McDermott et al. 1996).

The aim of the review was to identify and synthesize

recent studies on the relationship between nurse

empowerment and job satisfaction and to make rec-

ommendations for further research.

The following research questions guided this review:

● Can structural and psychological empowerment pro-

mote job satisfaction in nurses’ work environment?● What is the relationship between structural empow-

erment and job satisfaction in nurses’ work environ-

ment?● What is the relationship between psychological

empowerment and job satisfaction in nurses’ work

environment?

Methods

Design

A systematic literature review with narrative synthesis

was performed, because the methodologies of the

included studies were not appropriate for a statistical

summary of the studies. The integrative method pro-

posed by Whittemore and Knalf (2005) was used. This

method allows a combination of different method-

ologies to understand the varied perspectives on a spe-

cific phenomenon of concern better (Whittemore &

Knalf 2005).

Search strategy

The search included the following on-line databases:

MEDLINE (through PubMed), CINAHL (through EB-

SCOhost) and SCOPUS (through EBSCOhost). The

search period included articles published between

1998 and 2012 in order to select recent studies that

may have more relevance to the current nursing work-

place. The MeSH headings and free text terms were

combined to research the specific topic. Key search

terms included: workplace empowerment, nurse*,structural empowerment, psychological empowerment,

job satisfaction and work satisfaction. Two web sites

were searched for additional studies: Laschinger H.K.S.,

http://publish.uwo.ca/~hkl and Spreitzer G., http://webuser.

bus.umich.edu/spreitze/Empowerment_Research.htm.

For the search and retrieval process see Figure 1.

Inclusion criteria

The inclusion criteria for the studies were: (1) papers

published in English language, (2) with a study sample

that included nurses (no student nurses, no nurse edu-

cators, no nurse managers or assistant nurse managers),

(3) studies investigating the impact of empowerment

on job satisfaction and/or the relationship between

workplace empowerment and job satisfaction, (4) stud-

ies reporting direct measures of empowerment (struc-

tural and/or psychological) and job satisfaction, (5)

studies using CWEQ or CWEQ-II for measuring struc-

tural empowerment and studies using PES for measur-

ing psychological empowerment, (6) quantitative or

qualitative research designs, (7) peer reviewed research.

Screening

The selection of studies was conducted through an ini-

tial screening of the title and abstract in order to iden-

tify potentially relevant articles. Then, a screening was

carried out of all the full text articles identified as rele-

vant in the initial selection. Additional papers, not

identified in the initial literature search, were obtained

through examination of the references in the published

studies.

Each abstract was examined by two independent

reviewers according to the inclusion criteria. The

first author reviewed all titles and abstracts, deleted

duplication of articles and selected studies that

investigated the impact of empowerment on nurses’

job satisfaction. The second author, separately, eval-

uated a sample of titles and abstracts according to

the same inclusion criteria. Sixty-five titles and

abstracts were selected and full manuscripts were

retrieved for the first screening according to the

recruitment criteria. Twenty-three articles were

retained for the second screening using an inclusion

screening tool, adapted from Wagner et al. (2010)

(Figure 1).

Both reviewers agreed on which studies met the

inclusion criteria.

Fourteen articles were retained for quality assess-

ment and data extraction.

ª 2013 Blackwell Publishing Ltd

Journal of Nursing Management 3

Workplace empowerment – Review

Quality assessment

All articles were screened for quality using the pub-

lished ‘Quality Assessment and Validity Tool for Cor-

relational Studies’ adapted from previous systematic

reviews (Cummings & Estabrooks 2003, Estabrooks

et al. 2003, Wong & Cummings 2007, Cummings

et al. 2008, 2010, Wagner et al. 2010, Cowden et al.

2011) (Figure 2).

The instrument included 13 questions to scruti-

nize and score the research design, sample, measure-

ment and statistical analysis of the studies. The

questions were in the dichotomous answer format

and a total of 14 points could be assigned for the

13 criteria. Twelve items were scored as 0 (=notmet) or 1 (=met) and the items related to outcomes

measurement were scored out of two. Based on

scores assigned, the instrument classifies the articles

into three quality categories: low (0–4), medium (5–9)

and high (10–14).

Data extraction

Following the assessment for quality, 12 studies

remained for data extraction.

Data extracted from selected studies included:

author, year, journal, research question presented

(aim of the study), sample, response rate, independent

variable, dependent variable, measures, reliability and

validity of the instrument used, analysis and main

results.

Results

The electronic database search yielded over 1500

abstracts and titles. Following removal of duplicates,

the potentially eligible studies were screened. Some

573 studies were excluded. Quality assessments were

completed on 13 articles and following quality assess-

ment, one quantitative paper was excluded (Laschin-

ger et al. 2003). Twelve studies were included in the

final analysis.

Figure 3 illustrates the search and retrieval process.

Summary of quality review

Five studies included in the review were rated

high quality (Laschinger et al. 2004, Laschinger et al.

2001a,b, 2011, Ning et al. 2009). The seven remain-

ing studies were rated medium quality (Manojlovich

& Laschinger 2002, Laschinger 2008, Laschinger et al.

2009a, Lautizi et al. 2009, Cai & Zhou 2009, Cai

et al. 2011, Ahmad et al. 2010).

Most of the studies utilized a non-experimental,

cross-sectional design. Only one study used a longitu-

dinal design (Laschinger et al. 2004). All studies

were prospective in design as data were collected

prospectively.

Study: First author:

Publication date: :lanruoJ

Instructions for completion:noiretirchcaerofoNroseY.1

2. Record inclusion decision: article must satisfy six criteria .)7/6/5/3/2/1(

3. Record if additional references are to be retrieved Design: Sample:

1. Does the study measure structural empowerment using CWEQ or CWEQII? YES NO 2. Does the study measure psychological empowerment (Using Psychological Empowerment measuring tool)? YES NO 3. Is the relationship between empowerment and job satisfaction in nursing staff evaluated? YES NO 4. Is the relationship between workplace empowerment and other outcomes evaluated? YES NO Statistical analysis

ONSEY?eulav-PaerehtsI.5ONSEY?deifitnedicitsitatsaerehtsI.6

Which one(s)? ONSEY?edutingamfonoitacidninaerehtsI.7

ONSEYydutsedulcni:NOISICEDLANIF

Figure 1

Inclusion screening tool for correla-

tional studies.

ª 2013 Blackwell Publishing Ltd

4 Journal of Nursing Management

G. Cicolini et al.

Study: First author: Publication date: Journal:

DESIGN: NO YES1. Was the study prospective? 0 1

SAMPLE:1. Was probability sampling used? 0 12. Was sample size justified? 0 13. Was sample drawn for more than one site? 0 14. Was anonymity protected? 0 15. Response rate was more than 60%? 0 1

MEASUREMENT:Empowerment (IV) [assess for IV correlated with DVs only]1. Was the outcome measured reliably? 0 12. Was the outcome measured using a valid instrument? 0 1

Influence on the measure of job satisfaction (DV)?1. Was the dependent variable measured using a valid instrument? 0 1

2. If a scale was used for measuring the dependent variable, was the internal consistency ≥ .70?

0 2

3. Was a theoretical framework used for guidance? 0 1

STATISTICAL ANALYSIS1. If multiple outcomes were studied, are correlation analyzed? 0 12. Were outliers managed? 0 1

Overall Study Validity Rating (circle one) TOTAL: (0-4 = LO; 5-9 = MED; 10-14 = HI) LO MED HI

Figure 2

Quality assessment and validity tool

for correlational studies.

Records identified through database searching

1526

Additional records identified through manual and website search

92

596 Abstract screened for inclusion/exclusion

573Papers excluded

13Full-text articles included in

qualitative synthesis

1Full-text article

excluded

12Studies retained

23Full text screened for inclusion

screening tool

Figure 3

Search and retrieval process.

ª 2013 Blackwell Publishing Ltd

Journal of Nursing Management 5

Workplace empowerment – Review

Table 1 illustrates a summary of quality assessment

of studies included.

Strengths and weaknesses

The strengths in the selected studies for the review

included: use of a prospective design; use of probabil-

ity sampling and multicentric design; use of reliable

and valid instruments for the measurement of struc-

tural empowerment, psychological empowerment and

job satisfaction; study design based on theoretical

models to guide the research.

The most common weaknesses are related to sam-

pling and to the protection of anonymity. The selected

studies lack discussion about the protection of ano-

nymity of respondents and in probability sampling.

Furthermore there were no justifications of sample

size, based on appropriate power calculation.

Characteristics of selected studies

The characteristics of the studies included in this

review are summarized in Tables 2 and 3.

All studies had a quantitative research design and

were published between 2001 and 2011.

Seven studies were conducted in Canada (Laschinger

et al. 2011, Laschinger et al. 2001a, b, 2004, 2009a,

Laschinger 2008, Manojlovich & Laschinger 2002).

Three were conducted in China (Cai & Zhou 2009,

Cai et al. 2011, Ning et al. 2009), one in Italy (Lau-

tizi et al. 2009) and one in England and Malaysia

(Ahmad & Oranye 2010).

One study explored the correlation between empow-

erment and job satisfaction in psychiatric nurses from

both hospital wards and territorial health agencies

(Lautizi et al. 2009). The remaining 11 studies were

carried out in hospitals (Laschinger et al. 2009a, Ning

et al. 2009); in tertiary hospitals (Cai & Zhou 2009);

in acute care hospitals (Laschinger et al. 2011); in

urban teaching hospitals (Ahmad et al. 2010, Cai

et al. 2011) within different areas including medical-

surgical, critical care, maternal child and psychiatry

(Laschinger et al. 2001a,b, Laschinger et al. 2004,

Manojlovich & Laschinger 2002).

Two studies examined the relationships between

both structural and psychological empowerment and

job satisfaction (Ahmad & Oranye 2010, Laschinger

et al. 2004). Two studies reported results on the rela-

tion between both structural and psychological empow-

erment, job satisfaction and other measured outcomes

(Laschinger et al. 2001a, Manojlovich & Laschinger

2002). The remaining studies analysed the correlations

between structural empowerment, job satisfaction

(Ning et al. 2009) and other outcomes (Cai & Zhou

2009, 2011, Lautizi et al. 2009, Laschinger 2008, Las-

chinger et al. 2001b, 2009a, 2011).

Theoretical frameworks

Seven studies used an explicit theoretical framework

to guide the research (Manojlovich & Laschinger

2002, Laschinger et al. 2001a,b, Laschinger et al.

2004, Laschinger 2008, Lautizi et al. 2009, Ning

et al. 2009). Most of the studies used the Kanter’s

organisational empowerment theoretical model to

analyze the relationship between empowerment and

job satisfaction (Laschinger 2008, Ning et al. 2009,

Lautizi et al. 2009, Laschinger et al. 2001b, 2009a).

Kanter argues that the impact of organisational

structures on employee behaviour is more important

than the impact of employee personality predisposi-

tions (Kanter 1977). According to Kanter, the man-

date of management is to develop conditions for work

effectiveness by ensuring that employees have access

to the structure.

In addition to the model of empowerment (access to

information, support, resources and opportunity to

learn and grow), psychological empowerment is an

outcome of structural empowerment, and is useful

better to understand the influence of structural work

conditions on job satisfaction and other organisational

outcomes better (Wagner et al. 2010).

In contrast to Kanter’s theory, Spreitzer (1995)

focused more on the affective state of employees who

Table 1

Summary of quality assessment

Criteria

Number of

studies

No Yes

Design

Prospective studies 0 12

Sample

Probably sampling 9 3

Appropriate sample size 10 2

Sample drawn for more than one site 0 12

Anonymity protected 10 2

Response rate > 60% 6 6

Measurement

Reliable measure of outcome(s) 0 12

Valid measure of outcome(s) 0 12

Valid measure of empowerment 0 12

*Empowerment internal consistency � 70 0 12

Theoretical framework used 5 7

Statistical analysis

Correlation analysis when multiple effect studied 0 12

Management of outliers addressed 10 2

*Scores 2 points.

ª 2013 Blackwell Publishing Ltd

6 Journal of Nursing Management

G. Cicolini et al.

Table

2

Characteristicsofincludedstudies

Author(s)(year)

Journal;Country

Aim

Sample

Measurement/Instruments

Reliability/

Cronbacha

Validity

Caietal.(2011)

InternationalNursing

Review;China

Totestthejobcharacteristics

modelandthemediatingrole

ofstructuralempowerm

ent

(SE)ontherelationship

between

jobcharacteristicsandgeneral

jobsatisfactio

ngrowth

satisfaction

andinternalwork

motivatio

n

208nurses

CWEQ

II(C

onditionsforWork

EffectivenessQuestionnaireII),

4subsca

les

a=0.84

Previous

research

GeneralJobSatisfaction(G

JS),5items

a=0.85

Notreported

Growth

Satisfaction(G

S),4items.

a=078

Notreported

Internalwork

motivation(IWM),6items

a=0.74

Notreported

JobCharacteristicsIdaszac&Drasgow’s

(1997)revisionofJobDiagnosticSurvey,

5subsca

les,

30items

a=0.88

Notreported

Laschingeretal.(2011)

NursingResearch;

Canada

Totestamultilevelmodelto

examinetheeffectofstructural

empowerm

entandnursingunit

leadership

qualityonnurses’

burnoutandjobsatisfactio

nand

toexaminetherelatedpersonal

dispositionalvariables

3156nurses

CWEQ-II.(C

onditionsforWork

Effectiveness

QuestionnaireII),4subsca

les,12items

a=0.87

Construct

validity

JobSatisfactionSca

le(H

ackm

an&Oldham

1975),4items.

a=0.82

Construct

validity

LMX-m

ultidim

ensionalmodel,4dim

ensions

a=0.94

Construct

validity

CSEcore-selfevaluationscale,

4dim

ensions,

12items

a=0.78

Construct

validity

EmotionalExh

austion(EE)andCynicism

(C)

subscalesoftheMBI-GS

EE:a=0.92.C:a=0.94

Construct

validity

Ahmad&

Oranye(2010)

JournalofNursing

Management;Malaysia

Toanalyse

therelatio

nship

between

nurses’empowerm

ent,job

satisfactionandorganizatio

nal

commitmentin

twoteach

ing

hospitals

inEnglandand

Malaysia

556nurses

CWEQ

(ConditionsforWork

Effectiveness

Questionnaire),4subscales

H.Malaysia

a=0.864

H.Britisha=0.873

H.Malaysia

a=0.901

Construct&

content

validity

(Expert

Panel)

PES

(PsychologicalEmpowerm

entSca

le),

4dim

ensions,

12items

H.Britisha=0.898

IndexofJobSatisfactionScale,6components

H.Malaysia

a=0.793

H.Britisha=0.881

OCS(O

rganizatio

nalCommitm

entSca

le),

3dim

ensions,

18items

H.Malaysia

a=0.858

H.Britisha=0.783

Lautizietal.(2009)Journal

ofNursingManagement;

Italy

Toinvestigate

therelatio

nship

between

structuralempowerm

entin

staff

nurses,work

stressandjob

satisfaction

120nurses

CWEQ-II.(C

onditionsforWork

Effectiveness

QuestionnaireII),6components,19items

a=0.90

Construct

validity

JobSatisfactionSca

le(H

ackm

an&Oldham

1975)

a=0.67

Previous

studies

Stressscale

NA

Notreported

Ning(2009)Journalof

AdvancedNursing;China

Toinvestigate

therelatio

nship

between

structuralempowerm

ent,

demographicscharacteristicsand

jobsatisfactio

n

650nurses

CWEQ-II.(C

onditionsforWork

Effectiveness

QuestionnaireII),6components,19items

a=0.79–0.82

Construct

validity

MSQ

(Minnesota

Satisfaction

Questionnaire),20items

a=0.94

Notreported

Laschingeretal.(2009a)

JournalofNursing

Management;Canada

Toexaminetheinfluenceof

empoweringwork

conditionsand

workplace

incivility

onnurses’

burnout,jobsatisfaction,affective

commitmentandturnover

intention

612nurses

CWEQ-II.(C

onditionsforWork

Effectiveness

QuestionnaireII),6subsca

les,19items

a=0.79

Construct

validity

JobSatisfactionSca

le(H

ackm

an&Oldham

1975),4items

a=0.71

Previous

studies

WIS

(WorkplaceIncivility

Sca

le)

Supervisora=0.90

Co-w

orkers

a=0.86

Notreported

ª 2013 Blackwell Publishing Ltd

Journal of Nursing Management 7

Workplace empowerment – Review

Table

2

(Continued)

Author(s)(year)

Journal;Country

Aim

Sample

Measurement/Instruments

Reliability/

Cronbacha

Validity

EmotionalExh

austion(EE)andCynicism

(C)

subscale

oftheMBI-GS

EEa=0.91.C

a=0.82

Construct

validity

ACSAffective

Commitm

entScale.TurnoverIntention,

3items

a=

0.65

a=0.83

Previous

studies

Cai&Zhou(2009)Nursing

andHealth

Science

s;

China

Toinvestigate

thelevels

of

empowerm

entperceivedby

nursesandto

examinethe

relationship

betweenempowerm

ent,

jobsatisfactionandturnover

intention

189nurses

CWEQ-II.(C

onditionsforWork

Effectiveness

QuestionnaireII),4subsca

les+2itemsglobal

empowerm

entscale

a=0.76–0.85

Construct

validity

JAS(JobActivitiesSca

le),12itemsto

measure

form

alpower

a=0.80

Construct

validity

ORS(O

rganizatio

nalRelationship

Sca

le),

18itemsto

measure

inform

alpower

a=0.89

Construct

validity

GlobalJobSatisfactionQuestionnaire,5items

a=0.82

Notreported

TurnoverIntentionScale

(from

theMichigan

Organizatio

nalAssessmentQuestionnaire),

3items

a=0.86

Notreported

Laschinger(2008)Journal

ofNursingCare

Quality;

Canada

TotestLeiterandLaschinger’s

WorklifeModellinking

structuralempowerm

ent

toLake’s

5-factors

professional

practicework

environment

modelandwork

quality

outcomes

234nurses

CWEQ-II.(C

onditionsforWork

Effectiveness

QuestionnaireII),6subsca

les

a=0.68–87

Previous

studies

JobSatisfactionSca

le(H

ackm

an&

Oldham

1975),4items

a=0.77

Notreported

ProfessionalEnvironmentScale

(NWI-PES),

5itemsscale

a=0.81–0.87

Construct

validity

Qualityofnursingcare

onunit,1-item

scale

Notreported

Notreported

Laschingeretal.(2004)

JournalofOrganizatio

nal

Behavior;Canada

Totestamodellinkingchanges

instructuralandpsychological

empowerm

entto

changesin

jobsatisfaction(tim

e1and

time2)

185nurses

CWEQ-II.(C

onditionsforWork

Effectiveness

QuestionnaireII),6dim

ensions

Tim

e1a=0.60–0.81

Tim

e2a=0.68–0.87

Previous

studies

PES

(PsychologicalEmpowerm

entSca

le),

4dim

ensions,

12items

Tim

e1a=0.85–0.94

Tim

e2a=0.87–0.94

Previous

studies

JobSatisfactionSca

le(H

ackm

an&

Oldham

1975),4items

Tim

e1a=0.78

Tim

e1a=0.84

Construct

validity

ManojlovichandLaschinger

(2002)JONA;Canada

Tounderstandthedeterm

inants

ofjobsatisfactionforhospital

nurses

347nurses

CWEQ

(ConditionsforWork

Effectiveness

Questionnaire),4subsca

les

a=0.95

Previous

studies

PES

(PsychologicalEmpowerm

entSca

le),

4dim

ensions,

12items

a=0.88

Previous

studies

JobSatisfactionSca

le(H

ackm

an&

Oldham

1975),4items

Mastery

Scale

a=0.81

Notreported

a=0.80

Notreported

ModifiedversionofthePersonalityResearch

Form

-Achieve

mentSca

le

a=0.61

Notreported

Laschingeretal.(2001a)

NursingEconomics;

Canada

Toexplore

theinfluenceof

structuralempowerm

entand

psychologicalempowerm

ent

404nurses

CWEQ-II.(C

onditionsforWork

Effectiveness

QuestionnaireII),6dim

ensions

a=0.79–0.82

Content

PES

(PsychologicalEmpowerm

entSca

le),4

dim

ensions,12items

a=0.71–0.92

Content,

covergent

ª 2013 Blackwell Publishing Ltd

8 Journal of Nursing Management

G. Cicolini et al.

experience, or not, empowerment in workplaces. Two

studies used Kanter’s theory of structural empower-

ment in association with Spreitzer’s theory of psycho-

logical empowerment (Manojlovich & Laschinger

2002, Laschinger et al. 2004).

Laschinger et al. (2001a) used Kanter’s and Spreit-

zer’s theories and Karasek’s demands-control model

to explain the relationship between job strain in nursing

work environments, job satisfaction and structural and

psychological empowerment. Karasek (1979) argued

that job strain occurs when job demands are high and

job control is low within the work environment.

The results of this study suggested that the negative

relation between nurse empowerment and job strain is

consistent with both Kanter’s and Karasek’s theories.

Conceptual models

Four studies tested conceptual models (Laschinger

et al. 2004, Laschinger et al. 2009a, 2011, Laschinger

2008).

Laschinger et al. (2001a,b) used a longitudinal pre-

dictive design to test a model that linked changes in

structural and psychological empowerment to the

changes in job satisfaction.

Laschinger (2008) tested an extension of Leiter and

Laschinger’s nursing worklife model (Leiter & Lasch-

inger 2006) by linking nurses’ work environment con-

ditions to job satisfaction and perceived nursing care

quality. The findings of the study revealed that the

relationship between structural empowerment and

both work satisfaction and perceived nurses’ care

quality was mediated by the professional practice

environment characteristics.

Laschinger et al. (2009a) hypothesized a model in

which empowerment, incivility and burnout are

related to three retention outcomes: job satisfaction,

organisational commitment and turnover intention.

The results of this study provided support for the

hypothesized model.

Laschinger et al. (2011) proposed a multilevel model

of structural empowerment examining the effect of

nursing unit leadership quality and empowerment on

nurses’ burnout and job satisfaction at the unit and

individual level.

Measuring instruments of empowerment andjob satisfaction

According to the inclusion criteria, all of the studies

included measured structural empowerment with

CWEQ or CWEQ II and psychological empowerment

with PES.Table

2

(Continued)

Author(s)(year)

Journal;Country

Aim

Sample

Measurement/Instruments

Reliability/

Cronbacha

Validity

onnurse’s

jobstrain

and

work

satisfactio

n

and

divergent

Work

SatisfactionScale,4items

a=0.82

Content

Strain-m

odifiedJobContentQuestionnaire

a=0.82

Content

Laschingeretal.

(2001b)Health

Care

Management

Review;Canada

Totestamodellinkingstaff

nursework

empowerm

ent

andorganizationaltrustto

work

satisfactio

nand

organizatio

nalcommitment

412nurses

CWEQ-II.(C

onditionsforWork

Effectiveness

QuestionnaireII),6dim

ensions

a=0.93

Previous

studies

JAS

(JobActivitiesScale),12itemsto

measure

form

alpower

a=0.70

Faceand

content

ORS(O

rganizationalRelationship

Sca

le),18

itemsto

measure

inform

alpower

a=0.87

Content

Work

Satisfaction

Notreported

Notreported

InterpersonalTrustatWork

Sca

le,4subsca

les,

12items

a=0.84

Notreported

OCQ

(OrganizationalCommitm

ent

Questionnaire),3dim

ensions,

18items

a=0.74–0.75

Notreported

ª 2013 Blackwell Publishing Ltd

Journal of Nursing Management 9

Workplace empowerment – Review

Table

3

Relationshipsbetweenstructuralempowerm

ent(SE)/psych

ologicalempowerm

ent(PS)andjobsatisfaction(JS)

Relationship

betweenSEand/orPSandjobsatisfaction

Otheroutcomesmeasured

Relationshipsbetweenempowerm

entandotheroutcomes

1CorrelationbetweenSEandGJS

(r=0.492,P

=0.05)

CorrelationbetweenSEandGS(r

=0.741,P

=0.05).

Empowerm

entcompletely

mediatedtheim

pactofjob

characteristicsonGS(41.7%

ofthevariancein

GSis

attributable

toSE;b=0.811,R²=0.417,P

<0.0001).

Internalwork

motivatio

n(IWM).

JobCharacteristics

CorrelationbetweenSEandInternalWork

Motivation(r

=0.679,

P=0.01)CorrelationbetweenSEandJobCharacteristics(r

=0.803,

P=0.01).Empowerm

entpartially

mediatedtheim

pactofjob

characteristicsoninternalwork

motivatio

nsatisfaction(37.7%

ofthe

variancein

IWM

isattributable

toSE;b=0.970,R²=0.377,

P<0.0001)andtheim

pactofjobcharacteristicsonGeneralJob

Satisfaction(26.6%

ofthevariance

inGSis

attributable

toSE;

b=0.968,R²=0.266,P

<0.0001).

2SEhadasignificantdirectcross-leveleffecton

individuallevelnurses’JS

(b=0.30,P

<0.05).

Burnout,LMX(qualityrelationships

betweenleaders

andemployee),

core-selfevaluation.

AttheunitlevelhigherLMXwasasso

ciateswithigherSEon

theunit(b

=�0

.25).UnitlevelLMXhadasignificantdirecteffecton

unitlevelSE(b

=�0

.25,P

<.0.05)whichin

turn

hadasignificant

directcross

leveleffectonindividualnurses’jobsatisfaction.

SEhadasignificantnegative

cross-leveleffectonEE(b

=�0

.17,P

<0.05).

3CorrelationbetweenSE/PSandJS:significant

relationship

betweenthevariables,ataP-value=0.001

forboth

hospitalM

andhospitalS.

Organizatio

nalcommitment.

CorrelationbetweenSE/PSandorganizationalcommitment:significant

relationship

betweenthevariables,ataP-value=0.001in

hospitalM,

exce

ptforSEin

hospitalS(significantrelatio

nship

ataP-value=0.05).

4CorrelationbetweenSEandJS(r

=0.506,P

<0.001),

access

tosupportandJS(r

=0.51,P

<0.001),

opportunityto

learn

(r=0.51,P

<0.001),acce

ssto

inform

ation(r

=0.30,P

<0.001)andform

alpower

(r=0.31,P

<0.001).SEwassignificantpredictorof

JS

(R²=0.30,F=15.06,P

<0.001).

Work

stress.

CorrelationbetweenSEandnurse’s

work

stress(r

=�0

.28,P

<0.05).

Work

stresswassignificantpredictorofJS(R

²=0.30,F=15.06,P

<0.001).

5CorrelationbetweenSEandJS(r

=0.547,P

<0.01).

11.5%

ofvariance

inSEwasexplainedbya

combinationofageandwork

objective.Highlevels

of

SEwhennurseswere

youngandlovedtheprofession.

––

6SEexplained22.8%

(P<0.001)ofthevariancein

JS

whenenteredfirst(inmultiple

linearregressionanalysis).

SEwasastrongerpredictor(b

=0.28)ofJS.

Organizatio

nalcommitment,

turnoverintention.

Thepredictorvariables(SE,Incivility

andBurnout)acco

untedfor

46%

ofthevariancein

jobsatisfactionandfor29%

ofthevariancein

organizatio

nalcommitment.Thestrongestpredictors

ofturnover

intentionswere

cynicism

(b=0.27,P

<0.001),emotionalexhaustion

(b=0.19,P

<0.001)andsupervisorincivility

(b=0.16,P

<0.001).

Empowerm

entexplained19.2%

(P<0.001)ofthevariancein

organizatio

nalcommitment.SEwasstrongestpredictor(b

=0.31)of

organizatio

nalcommitment.SEwassignificantpredictorofturnover

intentions(b

=�0

.08,P

<0.05),butitwasweakerthanin

theprevious

models.

7Overallempowerm

ent(SE)waspositively

relatedto

JS

(r=0.56,P

=0.01).

Opportunity(r

=0.22,P

=0.01)andresources

(r=0.30,P

=0.01)were

positiverelatedto

JS.

Turnoverintention

Turnoverintentionwassignificantly

negative

lycorrelatedwithperceived

form

alpower(r

=�0

.27,P

=0.05),overallempowerm

ent

(r=�0

.31,P

=0.01)andjobsatisfaction(r

=�0

.49,P

=0.01).

8SEinfluencedlevelofJS:magnitudeoftherelationship

(0.45).

Professionalenvironment,quality

ofnursingcare.

Staffingadequacyinfluencedlevelofjobsatisfactio

n:magnitu

deofthe

relationship

(0.23).

Magnethospitalcharacteristicsmediated

theeffectofSEonnurses’perceptio

nsofpatientcare

qualityin

theirunit.

ª 2013 Blackwell Publishing Ltd

10 Journal of Nursing Management

G. Cicolini et al.

To measure job satisfaction, the studies included in

this review used five different measuring instruments.

Eight studies (Manojlovich & Laschinger 2002, Lasch-

inger et al. 2001a,b, Laschinger et al. 2004, Laschin-

ger et al. 2009a, 2011, Laschinger 2008, Lautizi et al.

2009) used a 4-item global measurement of work sat-

isfaction modified by Hackman and Oldham’s (1975)

job diagnostic survey. This measure has been used

previously in nursing populations (Laschinger &

Havens 1996) and it was found to have acceptable

internal consistency reliability (r = 0.83). All eight

studies included reported Cronbach alpha reliabilities

of >0.70.Cai et al. (2011) assessed job satisfaction by Idaszak

and Drasgows (1987) revision of the job diagnostic

survey. This tool measures both job characteristics

and outcomes which are job satisfaction (five items),

growth satisfaction (four items) and work motivation

(six items). The study reported alpha reliability coeffi-

cients of >0.70 for both job satisfaction and growth

satisfaction.

Ahmad and Oranye (2010) adapted the index of job

satisfaction scale (Stamps 1997) that measures job sat-

isfaction by six components: pay, autonomy, task

requirements, professional status, interaction and

organisational policies. In this study they reported a

Cronbach’s alpha coefficient in the range 0.79–0.81.

Ning et al. (2009) measured job satisfaction by the

Chinese version of the Minnesota satisfaction ques-

tionnaire (MSQ) (Jingji et al. 1980) consisting of 20

items. In this study the Cronbach alpha reliability of

the instrument was 0.94.

Another study, conducted in Central China (Cai &

Zhou 2009), used the global job satisfaction question-

naire with a 5-item global measure adapted from the

Revised Job Diagnostic Survey (Chinese version). In

previous studies the reported alpha reliability coeffi-

cients ranged from 0.71 to 0.86 and this study

reported a value of 0.80.

Correlations between empowerment andjob satisfaction

The relationship between empowerment and job satis-

faction has been studied in several countries, including

China, Italy and Malaysia, but the majority of the

research was carried out in Canada by Laschinger and

colleagues.

Several studies investigated the relation between

structural empowerment, job satisfaction and other

outcomes (Laschinger 2008, Cai et al. 2009, 2011,

Laschinger et al. 2001b, 2009a, Laschinger et al. 2011,Table

3

(Continued)

Relationship

betweenSEand/orPSandjobsatisfaction

Otheroutcomesmeasured

Relationshipsbetweenempowerm

entandotheroutcomes

9Changesin

perceptionsofSEproducestatistically

significantchangesin

PE(b

=0.38)andJS

(b=0.70).

––

10

SEpredicted29.5%

ofthevariancein

JS(R

2=0.29,

F=164.9,P

=0.001)

SEandPEtogetherpredicted38%

ofthevariance

inJS

(adjustedR2=0.38).

PEpredictedadditional7.2%

ofthevariancein

JS.

Both

SEandPEwere

significantindependentpredictors

ofJS(b

=0.39and0.33respectively).

Mastery

andAch

ievement

needs.

Mastery

needsdid

notmoderate

theempowerm

entsatisfactio

nrelatio

nship.

Mastery

needswere

weakly

relatedto

SE(r

=0.12),PE(r

=0.25)andJS

(r=0.14).

Ach

ievementneedswere

notstrongly

relatedto

anyvariables.

11

PEhadadirect

positiveeffectonJS

(b=0.30).

SEhadadirectpositiveeffectonJS

(b=0.38)andan

indirectpositiveeffectonJS

(b=0.15).

JobStrain

PEhadadirectivenegative

effectonjobstrain

(b=�0

.45).

Nonsignificantjobstrain/jobsatisfactionpath

suggests

thatoncetheeffect

ofPEare

accountedfor,jobstrain

isnotapredictorofwork

satisfaction.

12

SEhadboth

directandindirecteffectonJS.

HigherlevelofSEwere

associatedwithincrease

dJS

(b=0.46)(directeffect).

SEinfluencedwork

satisfactionthroughtrustin

management(0.141)(indirecteffect)

Interpersonaltrustatwork,

commitment

SEhadadirecteffectonaffectivecommitment(0.31)andan

indirecteffectthroughitsim

pactontrustin

management(0.16).

SEwasstrongly

asso

ciatedwithtrust(b

=0.51).

Trust

wassignificantlyandnegatively

associatedwithcontinuance

commitment(b

=�0

.18).

ª 2013 Blackwell Publishing Ltd

Journal of Nursing Management 11

Workplace empowerment – Review

Lautizi et al. 2009). Laschinger et al. (2001a,b) with job

satisfaction.

Two studies correlated both structural and psycho-

logical empowerment with job satisfaction and other

nurses’ outcomes (Laschinger et al. 2001a, Manojlo-

vich & Laschinger 2002, Ahmad & Oranye 2010).

Only one of the twelve studies included investigated

the relationship between job satisfaction and struc-

tural empowerment exclusively (Ning et al. 2009).

All the studies showed a significant positive correlation

between structural and psychological empowerment and

job satisfaction.

Structural empowerment, psychological

empowerment, job satisfaction and other

organisational outcomes

The only study that investigated the relationship between

structural empowerment and job satisfaction reported a

significant positive correlation between the two vari-

ables. It also showed that some demographic variables,

such as age and educational level, were statistically sig-

nificant in relation to structural empowerment and job

satisfaction exclusively.

Laschinger et al. (2001a,b) analysed the relationship

and the influence of changes in structural and psycho-

logical empowerment on changes in job satisfaction.

The data analysis of this longitudinal study suggested

that changes in perceptions of structural empower-

ment, produced statistically significant changes in job

satisfaction and psychological empowerment. Struc-

tural empowerment was directly and positive corre-

lated with job satisfaction. Moreover, changes in

structural empowerment predicted changes in job

satisfaction. These findings are supported by the high

quality of the study.

Nurses’ perceptions of leader-member exchange

quality on the unit level positively influenced their per-

ception of structural empowerment which, in turn,

culminated in higher levels of individual nurse work

satisfaction (Laschinger et al. 2011).

High levels of structural empowerment, low work

stress and low levels of incivility and burnout, predicted

job satisfaction (Laschinger et al. 2009a, Lautizi et al.

2009), commitment and turnover intention (Laschinger

et al. 2009a). Furthermore, turnover intention was neg-

atively correlated with job satisfaction and job activities

(Cai & Zhou 2009). However, these findings are sup-

ported by the medium-quality subgroup of studies.

Five studies examined the correlations between empow-

erment, job satisfaction and other positive outcomes in

the workplace. Only one study analysed these correlations

in two different societies (Ahmad & Oryane 2010).

Nurses’ perceptions of empowerment were directly

related to both job satisfaction and organisational

commitment. In particular, structural empowerment

had a direct effect on affective commitment (Laschinger

et al. 2001b, 2009a). Affective commitment is a type of

organisational commitment based on an individual’s

emotional attachment, involvement and identification

with an organisation (Meyer & Allen 1991).

Ahmad and Oryane (2010) found that there are dif-

ferences in the relationship between empowerment and

commitment among nurses who come from two differ-

ent cultural contexts: Malaysia and England. Among

Malaysian nurses, organisational commitment was

more closely related to psychological empowerment,

whereas the opposite was true among English nurses.

Structural empowerment completely mediated the

impact of job characteristics on growth satisfaction,

whereas it partially mediated the impact of job char-

acteristics on internal work motivation and general

job satisfaction (Cai et al. 2011).

Empowering work environments were linked to job

satisfaction and positive evaluations of the quality of

nursing care. In fact, empowering working conditions

play an important role in creating supportive profes-

sional practice environments that improve nurse

assessed patient care quality (Laschinger 2008).

Moreover, another study examined whether the

effects of structural and psychological empowerment

were moderated by specific personal factors: mastery

and achievements. Data analysis revealed that this

interaction was not significant (Manojlovich &

Laschinger 2002).

Structural empowerment had a direct, positive effect

on psychological empowerment that, in turn, had a

direct positive effect on job satisfaction and a direct

negative effect on job strain (Laschinger et al. 2001a).

Both structural and psychological empowerment were

significant predictors of job satisfaction. Although

structural empowerment predicted most of the

variance in job satisfaction by itself (Manojlovich &

Laschinger 2002).

Psychological empowerment has a significant posi-

tive relationship with job satisfaction and it has a

greater correlation than structural empowerment with

commitment (Ahmad & Oranye 2010).

Among the high-quality subgroup of studies, the

only longitudinal conducted study revealed that struc-

tural empowerment and psychological empowerment

play different roles in determining changes in the per-

ception of nurses’ empowerment and job satisfaction.

Structural empowerment directly affects job satisfac-

tion and at the same time produces changes in percep-

ª 2013 Blackwell Publishing Ltd

12 Journal of Nursing Management

G. Cicolini et al.

tions of psychological empowerment. However, psy-

chological empowerment does not cause direct

changes on satisfaction than those determined by the

structural. These results differ from those reported in

previous cross-sectional included studies (Laschinger

et al. 2004).

Discussion

The studies included in this systematic review exam-

ined the relationship between structural and/or psy-

chological empowerment and job satisfaction in the

nursing work environment.

Most of the studies used a theoretical framework,

which should be used in future research because it

provides a rationale to hypothesize conceptual models

and to test the relationships between ideas and vari-

ables (LoBiondo-Wood & Haber 1998).

The majority of the studies included in this review

were conducted by Laschinger and colleagues and

analysed the correlation between structural empower-

ment, job satisfaction and other organisational out-

comes. Recently, other authors have studied the

correlation between workplace empowerment and job

satisfaction in different cultural and organisational

settings (Cai et al. 2011, Ahmad & Oryane 2010,

Lautizi et al. 2009, Ning et al. 2009). Structural

empowerment was a stronger predictor of job satisfac-

tion in various organisational contexts and had a

significant direct effect at the individual level of

nurses’ job satisfaction (Laschinger et al. 2009a, 2011,

Ning et al. 2009). In particular, in the study of Lautizi

et al. (2009), carried out in the Italian context, job

satisfaction was strongly associated with the access to

support and the opportunity to learn.

A recent study provides support to the evidence that

structural and psychological empowerment concepts

may vary across cultures (Ahmad & Oryane 2010).

Furthermore differences in organisational contexts and

cultural values that influence nurses’ perceptions of

empowerment, could also influence the association

with job satisfaction (Ahmad & Oryane 2010).

Evidence were found concerning the correlations

between empowerment, job satisfaction and other or-

ganisational outcomes. According to previous studies

of job satisfaction, structural empowerment was a

stronger predictor of organisational commitment (Las-

chinger et al. 2001b, 2009a, Ahmad & Oryane 2010).

Psychological empowerment had a significant positive

relationship with job satisfaction but had a greater

correlation than structural empowerment with

commitment

(Ahmad & Oranye 2010). Furthermore, nurses with

low levels of self core evaluation (self-esteem, general-

ized self-efficacy, emotional stability and locus of con-

trol) were more likely to have high levels of emotional

exhaustion, cynicism, or both, which then reduced

their job satisfaction (Laschinger et al. 2011).

An empowering practice environment and a low

level of burnout in nursing settings were significant

predictors of job satisfaction, commitment and inten-

tion to leave (Laschinger et al. 2009a).

The combination of structural and psychological

empowerment was a strong predictor of positive

organisational outcomes, particularly job satisfaction

(Manojlovich & Laschinger 2002).

The link between structural and psychological

empowerment explained the empowerment process in

the work setting and how structural organisational fac-

tors are able to influence nurses’ feelings of personal

empowerment in workplaces (Laschinger et al. 2001a).

According to Kanter’s theory, social structural fac-

tors in the work environment are essential conditions

for empowering employees to accomplish their work.

The relationship with psychological empowerment is

consistent with Conger and Kanungo’s (1988) opin-

ion, which argues that removing disempowering struc-

tures from the work setting leads to a strong sense of

autonomy among employees, who have a strong belief

that they have an impact at work.

In the current context of the health care system, that

is under constant stress (Wagner et al. 2010) health

care managers have to consider the relationship

between empowerment and organisational outcomes,

and especially, they have to focus on job satisfaction

as a retention outcome.

To create an empowering work environment for

nurses, it is very important that nurse managers

(NMs) and assistant nurse managers (ANMs) are able

to obtain organisational support and to provide access

to resources and opportunity (Regan & Rodriguez

2011). Furthermore, a recent study has demonstrated

that empowered nurses are able to empower their

patients, and to obtain positive related health out-

comes (Laschinger et al. 2010).

Limitations

The review is limited to studies examining the relation-

ship between structural empowerment, psychological

empowerment and job satisfaction. Given that many

other organisational outcomes, such as intent to leave

(Fitzpatrick et al. 2010), respect (Faulkner & Laschin-

ger 2008), engagement (Laschinger et al. 2009b) and

ª 2013 Blackwell Publishing Ltd

Journal of Nursing Management 13

Workplace empowerment – Review

trust in organisation (Laschinger et al. 2000), are con-

sidered retention outcomes, our findings represent a

narrower part of the outcomes that are related to

empowerment.

Due to the nature of the variables investigated, no

randomized controlled trials (RCTs) were included in

the review. The majority of the studies used an obser-

vational, cross-sectional design. This factor could limit

the ability to estimate causation and decreased the

generalizability of the results (LoBiondo-Wood &

Haber 1998).

Nurse perceptions of empowerment in work envi-

ronments and nurse job satisfaction are assessed by

self-report measures, which are often associated with

response bias.

Finally, the variability in the measurement of job sat-

isfaction may limit the generalisability of the findings.

Implications for nursing management

This review provides encouraging support for efforts to

create satisfying healthy work environments that support

nurses’ practice in the workplace. Identifying the link

among nurse empowerment, job satisfaction and other

organisational outcomes will assist health care managers

to understand how empowerment improves retention

outcomes. Furthermore, these findings could be the start-

ing point for future research on the relationship between

patient care quality and quality of the professional prac-

tice environments.

The positive or negative influences of leadership

style could have an indirect impact on patient out-

comes by directly working on the nursing population

(Wong & Cummings 2007). Understanding the rela-

tionship between empowerment and job satisfaction

could help leaders not just to implement strategy for

retaining nurses, but also to improve patient care out-

comes (Ellenbecker & Cushman 2012).

Recommendations for future research

Based on the synthesis of findings in this review, sev-

eral recommendations arise for future research in this

area. The studies included in the review were observa-

tional or cross-sectional in design and this factor could

limit the generalisability of the results (LoBiondo-

Wood & Haber 1998). Among the high-quality sub-

group of studies included in this review, only one

study was longitudinal (Laschinger et al. 2004), therefore

there is a need to carry out longitudinal, intervention stud-

ies, to evaluate the causal relationships between nurse

empowerment and job satisfaction.

All the studies included in the review were multisite,

which should continue with further research, because

a diversity of multiple settings will add validity and

generalizability to the study findings (Cummings et al.

2010). However, sampling was collected from several

hospitals within the same system or region, and the

majority of the studies were conducted by Laschinger

and colleagues in Ontario (Canada) within an impor-

tant programme of research on workplace empower-

ment (Laschinger 2011). Further research is needed to

investigate the relationship between empowerment

and nurses’ job satisfaction in different countries. In

addition, most of the research was carried out in hos-

pital settings. To date, the relationship between struc-

tural and psychological empowerment and positive

organisational outcomes in different clinical settings

remains unknown.

Most of the studies used theoretical or conceptual

frameworks, which should continue to be used

because they provide a rationale to analyse the rela-

tionship between variables (LoBiondo-Wood & Haber

1998).

Finally, the findings of this review showed that no

studies were carried out to investigate the relationship

between workplace empowerment, job satisfaction

and patient outcomes. The relationship between job

satisfaction, quality of patient care and patients has

been extensively established (Ellenbecker & Cushman

2012). Moreover, a recent systematic review showed

that empowering work conditions support changes at

all levels of the organisation, provide positive long-

term outcomes for both managers and nursing staff

and improve patient outcomes (Wagner et al. 2010).

Currently, the specific relationship between empower-

ment, nurse job satisfaction and patient outcomes

remain an unexplored research area. Further research

is needed to investigate this specific topic and to assess

the relationship between workplace empowerment,

job satisfaction and patient outcomes on a larger scale

in a more diverse sample.

The first recommendation concerns the need to

carry out longitudinal intervention studies, to evalu-

ate the causal relationships between nurse empower-

ment and job satisfaction. Moreover, major studies

were conducted by Laschinger and colleagues in

Ontario (Canada), within an important programme

of research on workplace empowerment. There is an

urgent need to investigate the relationship between

empowerment and nurses’ job satisfaction in differ-

ent countries. In addition, further research is needed

to assess the relationship between workplace empow-

erment, job satisfaction, turnover intention and

ª 2013 Blackwell Publishing Ltd

14 Journal of Nursing Management

G. Cicolini et al.

patient outcomes on a larger scale in a more diverse

sample.

The majority of the research was carried out in hos-

pital settings. To date, the relationship between

structural and psychological empowerment and posi-

tive organisational outcomes in different clinical set-

tings remains unknown.

The literature shows that empowering work condi-

tions support changes at all levels of the organisation,

provide positive long-term outcomes for both manag-

ers and nursing staff and improve patient outcomes

(Wagner et al. 2010). The relationship between job

satisfaction, quality of patient care and patients has

been extensively established (Ellenbecker & Cushman

2012).

Currently, the specific relationship between empow-

erment, nurse job satisfaction and patient outcomes

remained an unexplored research area.

Conclusion

The findings of this review provide evidence of the

importance of workplace empowerment to achieve

positive organisational outcomes in nursing. Exploring

the impact of empowerment on nurses’ work environ-

ments and understanding the correlation between

empowerment and job satisfaction might be useful for

creating a supportive and satisfying work environment

for nurses, which in turn could promote the intention

to stay.

Structural empowerment is an antecedent variable to

psychological empowerment and this relationship culmi-

nates in positive workplace retention outcomes.

In all the studies analysed, the results indicate a

positive correlation between both structural and psy-

chological empowerment and job satisfaction and

other organisational outcomes. In particular, struc-

tural empowerment was a stronger predictor of job

satisfaction and organisational commitment, whereas

high levels of psychological empowerment were asso-

ciated with low levels of burnout.

This review could be useful to guide leaders’ strate-

gies to develop and maintain empowering work, so

enhancing job satisfaction, in turn leading to nurse

retention and positive patient outcomes.

Some of the studies included suggested that the posi-

tive correlation between empowerment and job satisfac-

tion could lead to positive patient outcomes. Despite

this, further research is needed, because there are no

intervention studies focused on the influence of empow-

erment in nurses’ job satisfaction and how this relation-

ship can positively affect patient outcomes.

Funding

Authors declare that no funding has been received for

this work.

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