After graduation, newly qualified nurses (NQNs) are expected to have an adequate skills set to ensure competency and safe nursing practice, including feeling sufficiently empowered and able to speak up against unsafe practice. The transition process from student to fully registered nurse has been described as stressful and challenging (Kaihlanen et al, 2013; Laschinger et al, 2016), and NQNs feeling unprepared, unsupported and disempowered (Laschinger et al, 2010; Gardiner and Sheen, 2016).
Empowerment is the process of controlling and sharing power with others, which encourages individuals to participate in decision-making and taking actions within the work environment (Tomey, 2004). Researchers have used empowerment theories to explain the complex factors that shape human empowerment behaviour. For example, Kanter's (1993) theory of structural empowerment centres on the organisation rather than the individual employee. It postulates that established organisational norms and customs/support, such as the opportunity for personal and professional growth, and access to resources and information, are instrumental in shaping staff empowerment. Kanter identified the following areas of access:
In addition to these components, the theory identifies two aspects of power: formal and informal. Formal power refers to specific job parameters such as flexibility, adaptability in decision-making, while informal power refers to informal social connections and communication channels across different levels of the organisation (Greco et al, 2006).
Research has shown that empowered nurses tend to have a more supportive work culture and higher job satisfaction (Laschinger et al, 2010). Kanter's theory of structural empowerment has been applied in research, looking at structural empowerment among NQNs. For example, Smith et al (2010) applied the theory when they surveyed 117 NQNs working in Canada to examine the impact of structural empowerment and other social variables on the nurses' organisational commitment. The researchers reported a moderate level of empowerment among participants. Similar studies in the UK (Mansour and Muttkokoya, 2018) and Saudi Arabia (Mansour et al, 2020) that used Kanter's theory to collect information about NQNs' experience of work also reported moderate levels of empowerment among participants. A study conducted to assess perceived levels of empowerment among Finnish NQNs showed fairly high level of perceived empowerment (Kuokkanen et al, 2016); however, the study used an alternative framework—the psychological model of empowerment from the perspective of motivation theory—to assess perceived empowerment, and so the results are incomparable with other published research findings. The perceived level of work empowerment of NQNs has also been found to be a predictor for other work experiences. For example, in a study undertaken by Laschinger et al (2010) in Canada, NQNs reported higher levels of work empowerment and they were found to have more learning opportunities, better job satisfaction and experienced less burnout.
Speaking up on behalf of patients, or being assertive when the need arises, is an important communication skill that all nurses, whatever their level of experience, must seek to acquire and practise (Nursing and Midwifery Council (NMC), 2018). Research has shown that NQNs struggle to speak up against unsafe practice, and often feel hesitant to demonstrate their moral courage to express their opinion, particularly when challenging colleagues higher up the management hierarchy (Murray et al, 2019). Moreover, they appear less inclined to speak up compared with their peers from other disciplines. A survey of 4496 newly qualified doctors, nurses and pharmacists found that nurses reported significantly lower confidence in term of speaking up and assertive communication (Ginsburg et al, 2013).
The perceived limited ability and willingness to be assertive in expressing their views, particularly when there is a perceived risk of patient harm, may lead NQNs to feel morally distressed, and subsequently experience burnout, low job satisfaction and potentially consider leaving the profession (Hazelwood et al, 2019). In this context, peer support and mentoring by senior nurses have been shown to enhance NQNs' confidence in speaking up. For example, Law and Chan (2015) conducted 18 qualitative interviews with NQNs to explore how they learn to speak up in practice. The findings suggest that NQNs' experience of speaking up is continuously shaped by educative and mis-educative experiences, and by the witnessed practice behaviours of those who mentor them, including nurses and other health professionals.
National professional bodies that regulate the nursing profession maintain that all nurses have a professional responsibility to speak up, intercept and escalate any perceived unsafe practices. For example, in the UK, the NMC (2018) requires all nurses to stand up and challenge unsafe practices; not doing so has the potential to result in a professional conduct investigation. However, NQNs and nursing students may not have yet fully developed the self-confidence or moral courage required to challenge any perceived unsafe practices, particularly when it involves more senior colleagues (Duffy et al, 2012).
Although it is a professional requirement for nurses to speak up about unsafe practices, the lack of a supportive framework to enable the NQNs to do so has arguably caused moral distress for many NQNs, who often feel powerless to translate these professional requirements into practice (Gallagher, 2011; Bickhoff et al, 2017).
According to the National Human Resources for Health Observatory, nurses working in Jordanian hospitals represent 38% of the country's health workforce (Al Hadid, 2014). The expansion of healthcare provision in Jordan over the past decade has meant that the number of NQNs in Jordanian hospitals has increased sharply, accounting for a significant percentage of the overall nursing workforce in the country (Al-Hussami et al, 2014). The increase has been partly ascribed to the mobility of the Jordanian nursing workforce, notably, their move to neighbouring Gulf Cooperative Council countries, resulting in NQNs in Jordan essentially becoming substitutes for more senior nurses who have left to work abroad.
Few studies have examined the concept of empowerment among the Jordanian healthcare workforce. For example, Saif and Saleh (2013) explored how psychological empowerment affected job satisfaction among staff in private hospitals; 554 people completed a 15-item psychological empowerment scale (Spreitzer, 1995) and a three-item job satisfaction scale. Participants perceived themselves to be highly empowered, which was correlated with a high level of job satisfaction. However, the study sample included all ‘hospital employees’, and there was little focus on the perceived empowerment of health professionals (such as nurses and doctors). Mudallal et al (2017) conducted a cross-sectional survey among 407 Jordanian registered nurses to examine how management initiatives could be used to empower and show employees that their contribution is valued, and provide them with opportunities to participate in decision-making, as well as how working conditions and demographics affected the risk of nurses experiencing burnout. The findings suggested that empowering behaviours were significantly correlated with subcategories of burnout. Four factors were linked to empowering behaviours among nurses: hospital type (public, private, teaching hospital), type of nurses' work pattern (fixed, rotating), providing autonomy and fostering participation in decision-making.
Although a handful of studies have examined the concepts of empowerment among Jordanian nurses (Saif and Saleh, 2013; Al-Dweik et al, 2016; Mudallal et al, 2017) there has been a dearth of research to investigate their speaking up behaviours, including those of NQNs. Little research has examined perceived assertiveness among NQNs in Jordan and its association with perceived organisational empowerment. The study described in this article aimed to examine the perception of structural empowerment among Jordanian NQNs, and their willingness to speak up against unsafe practices in clinical settings. The terms ‘organisational empowerment’ and ‘structural empowerment’ are used interchangeably to indicate the perceived level of empowerment within the organisation.
Method
Design
This study adopted a quantitative methodology, using a cross-sectional survey to collect information.
Sampling and participants
The healthcare system in Jordan is comprised of four healthcare sectors (public, private, military and educational), and covers the major three regions of Jordan (North, Central and South). Most of the hospitals (61.8%), however, are in the Central region (Al-Qaisi and Asaad, 2016): six of the region's largest hospitals (11% of its total of 54) were selected to recruit study participants.
Participants were recruited using convenience sampling and the potential study population included all NQNs working in the six hospitals—around 500 nurses—who met the study's eligibility criteria. The criteria included being an NQN with at least a bachelor's degree in nursing, having hands-on clinical experience of 18 months or less at the time of participation in the study, regardless of when the nurse had completed his/her undergraduate nursing education, and being registered with both the Jordanian Nurses and Midwives Council and the Jordanian Ministry of Health.
Instrument
Data were collected using a four-part self-report questionnaire: Part 1 includes collected information about participants' demographic details, such as age, gender, length of experience, and type of work setting. The second part included the Conditions of Work Effectiveness Questionnaire II (CWEQ-II) (Laschinger et al, 2001), which measured nurses' perception of work empowerment based on Kanter's (1993) Theory of Structural Empowerment. The CWEQ-II is a 19-item questionnaire divided into six subscales that examine participants' perceived access to opportunities, information, support and resources at work. The CWEQ-II also includes two additional subscales—formal power (three items) and informal power (four items)— that further enhance the examination of perceived structural empowerment; however, these were not part of the adapted version of the CWEQ-II that was used in this study. Collectively, these items ask participants to select their level of agreement with given statements using a 5-point scale, ranging from ‘none’ (1) to ‘a lot’ (5). Good internal consistency measures for the CWEQ-II have been reported in several studies (Cronbach's alpha>0.80) (DeVivo et al, 2013; Bish et al, 2014).
The third part of the questionnaire includes four hypothetical speaking-up scenarios that have been used and validated in previous studies examining nurses' assertive communication skills (Mansour and Muttkokoya, 2018; Mansour et al, 2020). The four thought-provoking scenarios are typical of what nurses commonly face in clinical settings:
For each scenario (Box 1) participants indicated on a 5-point Likert scale the likelihood of taking the action suggested at the end to prevent patient harm, with higher scores indicating a greater likelihood of speaking up and preventing unsafe practice occurring, or taking action to safeguard the patient. These hypothetical scenarios had been used previously and demonstrated acceptable internal consistency (α=0.76) when tested on a sample of NQNs in the east of England (Mansour and Muttkokoya, 2018) and acceptable consistency (α=0.69) when tested with Saudi NQNs (Mansour et al, 2020).
| We are interested in your opinions on the following hypothetical scenarios | Response | |
|---|---|---|
| Scenario 1 | You are giving a full bed bath to Mr Thomas, who is a 72 years old, bed-bound patient. A senior colleague is helping you. You want to move Mr Thomas up the bed. Your colleague has suggested not using a sliding sheet because ‘the patient is not very heavy’. |
Very unlikely 1 |
| Scenario 2 | On the night shift, you are working with a senior staff nurse who is a very good friend of yours. |
Very unlikely 1 |
| Scenario 3 | You are doing your evening medication round, and one of your patients asked you about ‘this blue tablet’ he has just taken and states that he has never had it before. You check his drug chart and realise that the tablet is warfarin, and the patient was not meant to have it at this time. |
Very unlikely 1 |
| Scenario 4 | You have the curtains around Mrs Jones's, a 76-year-old patient's, bed and you are assisting her to get dressed following a bedbath. Mrs Jones has very little clothing on and a young male doctor puts his head through the curtains. Mrs Jones looks uncomfortable about the doctor's presence. You expect him to make an apology and leave, but he begins to talk to the patient about a new course of medications he will be giving her. The doctor does not acknowledge that you are there and Mrs Jones becomes agitated and distressed. |
Very unlikely 1 |
The fourth part of the questionnaire includes qualitative questions that are not reported in this article.
Data collection
After securing ethical approval, a research assistant (RA) met with the nursing administrations of the participating hospital sites to seek permission to invite eligible nurses to take part. Nurses who agreed to participate met the RA face to face and were provided with the questionnaire in a sealed envelope. They were asked to complete this and return it to the RA, who returned to collect them towards the end of that day's shift and a few days later. Alternatively, participants had the option of dropping off their completed questionnaire into a designated letterbox installed in each ward/unit. A total of 280 questionnaires were distributed; the response rate was more than 80%. Data collection took place between January and March 2016.
Ethical considerations
The study was reviewed and approved by the Scientific Research Committee at the School of Nursing at the University of Jordan, and the ethics committees of participating hospitals.
Data analysis
The Statistical Package for Social Science (SPSSv21) software was used to analyse the data. Descriptive statistics (means and standard deviations) were measured to describe participants' demographic characteristics and examine their responses on the questionnaires. For the CWEQ-II, the mean score for each of the four subscales was calculated, which were then combined to create the total structural empowerment (TSE) score, which ranged from low (4–9) to moderate (10–14) and high (15–20) (Laschinger et al, 2010). Participants' responses on each of the speaking-up scale items were combined and averaged to calculate the mean score. The total speaking-up score for all subscales was in the range of 4–20. Higher scores suggest a greater willingness to challenge unsafe practices.
The instruments, including the hypothetical scenarios, were piloted with 20 nurses, following which the questionnaire underwent some minor editing.
The result of Kolmogorov-Smirnov (K-S) test of normality confirmed that both TSE and average score on the speaking up scale followed a non-normal distribution. Moreover, the use of ordinal variables in the data analysis violates the criteria for using a parametric correlation test (Field, 2013). Therefore, a non-parametric correlation coefficient (Spearman's) was used to examine the correlation between TSE and the average score for the speaking-up scale.
Results
A total of 233 valid questionnaires were returned of the 280 invited to participate (83.2% response rate). As Table 1 shows, most participants were women (74% n=172), aged less than 25 years (59% n=137), their clinical experience was 13-18 months (56% n=130), almost half worked in private hospitals (49% n=114), and a considerable percentage worked in intensive care units (40% n=94).
| Variable | n | (%) | |
|---|---|---|---|
| Gender | Male | 59 | 25.3 |
| Female | 172 | 73.8 | |
| Not indicated | 2 | 0.86 | |
| Age | 20–25 | 137 | 58.8 |
| 26–30 | 74 | 31.8 | |
| More than 30 | 21 | 9.0 | |
| Not indicated | 1 | 0.43 | |
| Length of experience (months) | 1–6 | 45 | 19.3 |
| 7–12 | 55 | 23.6 | |
| 13–18 | 130 | 55.8 | |
| Not indicated | 3 | 1.3 | |
| Current area of work | Medical-surgical floor | 67 | 28.8 |
| Intensive care units | 94 | 40.3 | |
| Emergency unit | 31 | 13.3 | |
| Others | 40 | 17.2 | |
| Not indicated | 1 | 0.43 | |
| Healthcare sector | Public | 46 | 19.7 |
| Private | 114 | 48.9 | |
| Military | 47 | 20.2 | |
| Educational | 26 | 11.2 | |
| Higher education sector | Public | 155 | 66.5 |
| Private | 78 | 33.5 | |
Table 2 shows the mean scores (M), standard deviations (SD) and Cronbach's alpha for all the scales used in the survey. Cronbach's alpha for the CWEQ-II scale was 0.84, which is very good and is consistent with previously reported internal consistencies of the scale when tested on samples from culturally diverse populations. (Laschinger et al, 2010; Mansour and Mattukoyya, 2018). For the speaking-up scale, the initial Cronbach's alpha was 0.54, which is poor. However, when the first item was deleted, the scale reliability increased to 0.66, which is considered acceptable (Field, 2013). Therefore, the first scenario in the speaking-up scale was deleted, and the remaining three items were retained for further analysis.
| Variables | Alpha | Mean (SD) |
|---|---|---|
| Opportunity | 0.70 | 3.15 (0.83) |
| Information | 0.78 | 2.85 (0.83) |
| Support | 0.76 | 3.03 (0.79) |
| Resources | 0.80 | 2.88 (0.90) |
| Formal power | 0.72 | 2.32 (0.79) |
| Informal power | 0.68 | 3.16 (0.76) |
| Total speaking up score | 0.66 | 3.56 (0.66) |
| Total structural empowerment score | 0.84 | 11.92 (2.53) |
The participants reported a moderate level of perceived TSE (M=11.92, SD=2.53), with access to informal power having the highest score (M=3.16, SD=0.76), and access to formal power having the lowest score (M=2.32, SD=0.79). Similarly, participants reported a moderate score on the willingness to speak up scale (M= 3.56, SD=0.66).
Table 3 shows the correlation between participants' perception of structural empowerment and their perceived willingness to speak up about unsafe practice in the indicated hypothetical scenarios. There was a statistically significant positive correlation between the TSE score and mean score on the speaking-up scale (r=0.19, P<0.01). A statistically significant positive correlation was also found between the mean score on the speaking-up scale and access to information (r=0.178, P<0.01), resources (r=0.22, P<0.01) and formal power (r=0.16, P<0.05).
Discussion
The results of this study show that NQNs had a moderate level of perceived structural empowerment (M=11.92, SD=2.53). This result is consistent with findings from previous research involving NQNs that examined perceived structural empowerment (using the same CWEQ-II), such as studies undertaken in the UK (M=13.8. SD=0.52) (Mansour and Muttkokoya, 2018), Canada (M=13.46, SD=2.4) (Laschinger, 2012), and Saudi Arabia (M=13.53, SD=2.6) (Mansour et al, 2020), which all reported a moderate level of empowerment, Similarly, participants in the study described in this article reported a moderate level of willingness to speak up against perceived unsafe practice in the hypothetical scenarios.
These results confirm previous findings that administered similar hypothetical scenarios with NQNs, and where nurses reported a moderate level of willingness to speak up against unsafe practice (Mansour and Mattukoyya, 2018; Mansour et al, 2020). With the passage of time, as nurses gain more experience, they are more likely to develop self-confidence in their communication skills, but also discover their moral courage to challenge unsafe practice. One study found that senior nurses were more likely to speak up compared with junior colleagues, although they admitted that their decision to speak up was based mainly on their perception of clinical safety issues and the risk of harm to the patient in future (Schwappach and Gehring, 2014).
The findings show a statistically significant positive correlation between participants' TSE score and their speaking up mean score, as well as an adequate correlation between the speaking up mean score and access to information, resources and formal power score. This may suggest that the process of learning to speak up is likely to be influenced by management's approach toward nurses, which needs to grant them a sufficient level of autonomy, power, and access to resources, all of which are considered prerequisites for developing the confidence to speak up (Law and Chan, 2015). Moreover, NQNs need the resources and support of their employers to facilitate safe nursing practices (Odland et al, 2014). The findings also underscore the need for effective training on how to speak up and how a positive working culture and good peer support can help consolidate the acquisition of assertive communication skills, and build self-confidence by focusing on their own values (ie moral courage) and other human factor dimensions, such as re-engineering assertive communication methods (Wing et al, 2015).
Limitations
In this study, the fact that participants self-reported information has limitations for the interpretation of the data collected. In addition, most participants were female and worked in private hospitals. In Jordan, nurses working in private hospitals have been reported to have significantly higher levels of job satisfaction and intention to stay (AbuAlRub et al, 2009; Mrayyan, 2005), but they have lower job security compared with their colleagues working in publicly funded hospitals. In the study reported here, this may therefore have affected the NQNs' perceived empowerment and willingness to speak up. For this reason, the over-representation of nurses from private hospitals indicates the need for caution when interpreting the findings in terms of extrapolating them to all NQNs, including those working in the other Jordanian healthcare sectors.
Conclusion
The early years of practising as a nurse were reported to be a significant time for building confidence, shaping professional identity and work socialisation, which are essential pillars for delivering safe nursing care (Andregård and Jangland, 2015). Both the participants' responses to statements on the speaking up scale, as well as their perceived level of empowerment, were found to be positively correlated. This finding emphasised the impact of support from peers, managers and the organisation overall in enabling the NQNs to become more empowered and assertive in their work environment.
It is imperative that an organisational culture supports the development of an empowering work environment where NQNs feel both empowered and able to speak up against unsafe practice. Moreover, inhouse professional development programmes should have a clear focus on developing nurses' self-empowerment in their organisation to improve hospital-wide awareness of the importance of speaking up as a pillar for the safe delivery of patient care. Nurse managers, education specialists and policymakers must consider organisation-wide approaches that will help empower NQNs in their work settings, and revisit work priorities to include supporting and advocating the development of assertive communication skills among more vulnerable NQNs.
The findings of this study serve as a platform for further research to examine more closely what constitutes assertive communication skills, and to propose and test strategies to help NQNs develop such important, yet hard-to-acquire communication skills and apply them effectively in clinical practice. Unlike the CWEQ-II, which performed reasonably well on the reliability measure, the speaking-up scores initially showed poor internal consistency measures, which indicates the need for further examination, and potentially adaptation, of the CWEQ-II for use with different sample populations.