1. Linnen, Daniel MS, BSN, RN, CCRN
  2. Rowley, Adam BSN, RN

Article Content

You're on your way home from a hectic and frustrating day at the hospital. Even though your unit was fully staffed, you're feeling stressed and disappointed. For weeks, you've been too busy to meet with your team to discuss their ideas for reducing patient falls on the unit. Today, you were informed that a meeting is no longer needed because a systemwide fall reduction plan will soon be implemented.

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After reviewing the new plan, some of your direct reports realized that many parts of the fall reduction strategy don't make sense for your unit and important ideas were omitted, yet they expressed a powerlessness to effect change. The hospital expects you to "own your practice" by adopting the new top-down policy-but where's clinical nurse input? You're concerned that your staff members will start to feel burned out and disillusioned, and may even look for new positions in a different hospital.


Should it really have to come to this? What makes some teams succeed while others struggle? We give you an overview of recent research and evidence about the benefits of empowerment and present recommendations for professional nursing and healthcare leadership.


What's empowerment look like?

Structural empowerment means implementing organizational strategies that support shared team governance, open leadership communication, and supportive and empathetic nursing team relationships. Structural empowerment has a positive effect on individual nurse empowerment by raising the clinical nurses' positive perception of empowerment at the workplace. This, in turn, has a motivating effect, and it raises overall job satisfaction.1 Creating an empowered team is a vital nurse leadership function that can significantly influence staff morale, productivity, staff retention and associated costs, patient care, quality, and patient safety.2


Reasons for loss of empowerment

Many nurses leave their positions because of negative experiences with heavy or unrealistic workloads and due to feeling unheard and undervalued, if not worse.3 Clinical nurses' sense of disempowerment can be related to deficient leadership interventions. For instance, clinical nurses may feel that managers are insensitive to their staffing needs, don't support employee well-being, and don't invest enough in staff education or clinical advancement.4


Even seemingly positive changes, when introduced to a unit without staff input, might result in lack of buy-in because nurses perceive this as being told "how to do our job." In contrast, empowered teams are supported by inclusive, nonauthoritarian, visionary, and emotionally intelligent leadership.5-8


Fiscal impact of poor retention

Nurse job dissatisfaction can lead to staff turnover, which comes at a high price. According to the Robert Wood Johnson Foundation, the mean replacement cost of one clinical nurse is as high as $63,000 in a major West coast metropolitan area.9 Costs vary widely depending on factors such as clinical specialty, hospital location, and the clinical nurses' years of employment. The many fiscal benefits of retaining clinical nurses include reduced costs related to termination, position vacancy, overtime, advertising, recruitment, training, and orientation.9


Nurse turnover has significant financial implications, especially considering that the next nursing shortage is looming; the demand for nurses will only increase as more baby boomers enter retirement. For example, in a hypothetical workforce of 300 RNs, the highest reported average annual turnover of 13.9% equals a mean liability of $2.6 million in annual replacement expenditures (assuming a replacement cost of $63,000 per vacancy).9


Besides reducing nurse turnover costs, healthcare organizations committed to staff empowerment, job satisfaction, and a healthy work environment have better patient outcomes, shorter lengths of stay, decreased mortality, and higher patient satisfaction scores.9 A structure of shared decision making lets nurses advocate for their patients more effectively, initiate positive change, and improve patient safety and quality of care.2


More than direct reports

"Nothing about me without me" is the key phrase for more empowerment of clinical nurses. Clinical RNs must see themselves as professional stewards of their unit, rather than as employees who clock in and out for a paycheck. Empowerment isn't something to be bestowed by hospital managers and executives. Nurses are leaders by virtue of their responsibilities; for them, empowerment isn't a privilege, but a professional necessity.


Consequently, leadership is no longer the job of unit managers and senior leaders alone. Healthy teams engage in a shared vision of unit ownership rather than a hierarchical and authoritarian employee-employer relationship. Leaders have to be willing to share unit governance, support the formation of unit councils, and actively engage nurses in unit business.2,7,10


Unit practice councils may benefit by adopting the five-factor professional practice work environment model. Eileen Lake, PhD, RN, is a nurse scholar and researcher who's published many studies investigating practice environments that support professional nursing. Her model includes five tenets:


1. nurse advancement


2. staff participation in policy and governance


3. nurse manager's leadership and support


4. staffing and resource adequacy


5. collegial nurse-physician relations.11



Recommendations for leaders


* Clinical nurses and unit managers should foster a team approach that encourages shared governance, ownership of practice, and the expression of ideas and opinions in unit councils and committees. (See supplemental content on the Nursing Management iPad app.)


Improved staff empowerment is clearly linked to these propositions. Top-down care strategies from senior leaders must be paired with bottom-up unit champions that allow customization. The traditional role of nursing as solely concerned with patient care (without involvement in the operational framework) seems to stem from nurses' historically disempowered role within the healthcare system. Nursing today calls for active participation and leadership from clinical staff. All members of unit teams should recognize that the historical context of top-down leadership in our profession is outdated, rather than defaulting to traditional and convenient views of leadership as authoritarian and hierarchical. Some clinical nurses prefer to be detached from unit governance, but this gives them an "us versus them" perspective and creates little impetus for positive change. Such lack of team engagement leads to increased staff turnover and loss of care quality over time.2,5


* Key leadership skills for clinical nurses and team leaders are emotional intelligence (EI), trust, a visionary attitude, and commitment to a participative, consistent, and nonauthoritarian work environment.



This realization has twofold significance. First, it serves as a guide for the development of positive leadership skills in clinical nurses and managers alike. Good leaders build trust, listen, show empathy, model desired behavior, behave consistently, manage frustrations and conflict in self and others in a mature way, and inspire others to achieve success. Second, management applicants should be screened for these qualities and their psychological disposition during the hiring process; recruiters need to evaluate more than just years of experience and clinical expertise. Recruiters and hiring directors should screen for a leader's ability to support empowered teams and traits of autocratic management style or tendency to micromanage (control all aspects of an operation or task).


* When managers aren't overloaded with supervisory duties, they can improve productivity and empower their staff.



Behavior leading to disempowerment doesn't always result from a lack of EI or unwillingness to inspire; instead, it may reflect the clinical nurses' and managers' workload. Most managers work more than 8 hours per day just to stay on top of operational needs. Adding tasks, such as covering a unit for an absent manager, takes away most of the time needed to create an empowered staff. Structural empowerment requires open time slots for clinical nurses and managers to connect in meaningful ways without interruptions.


* Clinical nurses should see empowerment as the norm rather than as a luxury. Nurse executives and unit managers should give more weight to the "business case" of clinical nurse empowerment and advocate for healthy workplace quality indicators.



Don't underestimate the cost savings of staff retention resulting directly from staff empowerment. In addition, no team can deliver the best possible care for patients when morale is low, nurses are burned out, and their voices and concerns are largely being ignored. Senior leaders should strive for Magnet recognition, not for its prestigious reputation, but for its reflection of values and principles fostered at the top. Accrediting agencies, too, could consider including staff empowerment as an accreditation factor.


Improving practice

The empowerment of clinical nurses still seems to occur largely on a local level with limited external recognition (with Magnet(R) status being a noteworthy exception). Employers, managers, and nurses on unit teams can either support or diminish structural empowerment and healthy workplace characteristics. Implementing strategies that support shared governance, open communication, and supportive and empathetic team relationships is clearly in the best interest of all health systems participants.




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