Journal of Nursing Management, 2010, 18, 24–34

Impact of critical social empowerment on psychological

empowerment and job satisfaction in nursing and midwifery
settings

1 2 3
MARIE CASEY BSc(Hons), MBA, RM, RN , JEAN SAUNDERS PhD and TERESA O’HARA PhD
1
Regional Professional Development Officer, HSE Mid West, Limerick, 2Executive Director, Department of
Mathematics and Statistics, Statistical Consulting Unit, University of Limerick, Limerick and 3Adjunct Lecturer,
School of Business, Dublin City University, Dublin, Ireland

Correspondence C A S E Y M . , S A U N D E R S J . & O ’ H A R A T . (2010) Journal of Nursing Management 18, 24–34

Marie Casey Impact of critical social empowerment on psychological empowerment and job
Regional Professional Development satisfaction in nursing and midwifery settings
Officer
HSE Mid West Aim To test an expanded model of empowerment which specifies the relationships
Catherine Street between structural, psychological, critical social empowerment and job satisfaction.
Limerick Background There is evidence that structural empowerment predicts psychological
Ireland empowerment and these two dimensions of empowerment are independent pre-
E-mail: marieecasey@aol.com dictors of job satisfaction. This study explored a third dimension of empowerment –
critical social empowerment – and its impact on psychological empowerment and
job satisfaction.
Method A predictive, non-experimental design in a sample of 306 nurses and
midwives in Ireland using the Conditions of Work Effectiveness Questionnaire, the
Psychological Empowerment Questionnaire, a researcher developed tool to measure
critical social empowerment and a job satisfaction questionnaire.
Results While both structural and critical social empowerment were significant
independent predictors of psychological empowerment and job satisfaction, critical
social empowerment was the stronger predictor.
Conclusions The findings support the inclusion of the critical social dimension of
empowerment in the understanding of empowerment.
Implications for nursing management Managers at all levels must attend to critical
social empowerment as well as structural empowerment in order to increase job
satisfaction, retention and engagement of highly qualified committed nurses and
midwives.
Keywords: critical social, job satisfaction, psychological and structural empowerment

Accepted for publication: 17 July 2009

imaginative problem solving by healthcare professionals

Introduction
Today, more than 70% of organizations surveyed have
adopted some kind of empowerment initiative for some
portion of their workforce, demonstrating its impor-
tance (Spreitzer & Doneson 2005). Innovation and
24
depends on empowerment (Sofarelli & Brown 1998).
Klein (1998) argues that not enough nurses are leaders
so they are unable to influence health administrative
staff to prioritize meeting patientsÕ needs. The Institute
of Medicine (2004) report noted that patient care
DOI: 10.1111/j.1365-2834.2009.01040.x
ª 2009 The Authors. Journal compilation ª 2009 Blackwell Publishing Ltd

quality and safety relates directly to how empowered
nurses are to influence care plans and contribute to
organizational decisions. Empowerment has also been
linked to the mental and physical health of nurses
(Laschinger & Finegan 2005a).
Empowerment theory focuses on fundamental ques-
tions of political philosophy; the nature of power, the
role of the citizen in the polis and the achievement of
justice in civic life (Spreitzer & Doneson 2005). With-
out empowerment, employees find little meaning at
work. Modern empowerment literature focuses on
alleviating this lack of meaning. Spreitzer and Doneson
(2005) describe a new movement in organizational
studies ÔPositive Organizational ScholarshipÕ (POS).
POS examines Ôpositive devianceÕ, where employees
transcend set norms and take calculated risks to achieve
extraordinary outcomes because their work has mean-
ing. Spreitzer and Doneson (2005) explain that in view
of the accepted fact that norms provide a means of
control over what people say and do, positive deviance
requires real risk and often makes others feel uncom-
fortable. Empowered employees take responsibility,
take calculated risks and Ôbuild the bridge as they walk
on itÕ (Quinn 2000). To do this, they must clarify their
values, look inside and make painful adjustments in
their own behaviour to overcome hypocrisy between
what they say and what they do (Quinn 2000).
Therefore, no one can truly empower anyone else
(Spreitzer & Doneson 2005). However, managers can
foster empowerment by creating an environment where
nurses and midwives are involved in decision-making
and freed from over restrictive control (Lewis &
Urmston 2000). Spreitzer and Doneson (2005) advise
organizational development facilitators to release the
power in the workforce to take initiatives for the
organizational good. This contrasts with the disem-
powering notion of power transfer as power could just
as well be taken away again.
Theoretical framework for the study
Contemporary literature on empowerment highlights
three theoretical perspectives: the structural, the psy-
chological and the critical social.
The structural perspective
This focuses on power sharing in organizations through
participation and involvement at all levels. Whereas in a
democracy all citizens have an equal vote, in bureau-
cratic organizations senior managers have more say
(Eylon 1998). A fundamental model of job-related
empowerment has been provided by Rosabeth Moss
ª 2009 The Authors. Journal compilation ª 2009 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 24–34
Job satisfaction in nursing and midwifery settings
Kanter (1977, 1993) in her seminal work on the theory
of power and its structure in organizations. Kanter
maintains that social structures in the workplace influ-
ence employee behaviour and attitude to a greater de-
gree than individual personality characteristics or
socialization effects. KanterÕs empowerment structures
in the work environment are outlined in Table 1. When
employees have access to formal and informal power,
they have greater access to information, support and
resources, and opportunities to learn and grow.
KanterÕs model has been tested extensively, first by
Chandler (1991) in a healthcare setting with 246 nurse
administrators. Later studies found moderate relation-
ships between work empowerment and formal and
informal power (Sabiston & Laschinger 1995, DOH &
C/DCU 2003). Patrick and Laschinger (2006) examined
the relationship between structural empowerment and
perceived organizational support and the effect of these
factors on the role satisfaction of 84 middle level nurse
managers in Ontario, Canada and found they were
significant predictors of role satisfaction.
The psychological perspective
KanterÕs theory of structural factors pays little attention
to personality or individual factors. Conger and Kan-
ungo (1988) were the first to develop the theory of
psychological empowerment from the perspective of
motivational theory. Thomas and Velthouse (1990) and
Spreitzer (1995) independently identified four dimen-
sions to psychological empowerment: meaning of the
work, competence, self-determination and impact on
the outcomes of work, which together reflect a proac-
tive orientation to a work role (Table 2).
Spreitzer (1995) states that psychological empower-
ment is not an enduring personality trait, but is shaped
Table 1
Components of structural empowerment
Structural empowerment
Opportunity A sense of challenge and chance to grow and
develop
Information Data, knowledge and expertise, and awareness
of organizational goals
Support Problem-solving advice, feedback and guidance
received from senior managers, peers and
direct reports
Resources Time, supplies, and equipment to accomplish
organizational goals
Formal power Jobs that afford flexibility and visibility, and that
are relevant to key organizational processes
Informal power Network of alliances with sponsors, senior
managers, peers and direct reports within and
outside the organization
25
M. Casey et al.
Table 2
Components of psychological empowerment
Psychological empowerment (Spreitzer 1995)
Meaning Congruence between job requirements and
individualÕs beliefs
Competence IndividualÕs belief in capability to accomplish
work to be done
Self-determination Autonomy in work behaviours and processes
Impact Sense of being able to influence organizational
activities and outcomes
by a work environment and so is specific to the work
domain.
Data gathered from 93 nurses and midwives (DOH
& C/DCU 2003) identified personal factors such as
autonomy, education, skills, self-direction and standing
by professional decisions as important for empower-
ment. Laschinger et al. (2001) found that nurses who
experienced a high degree of control in their jobs,
however psychologically demanding, were more psy-
chologically empowered, as measured by SpreitzerÕs
(1995) scale. They conclude that managers should cre-
ate conditions that optimize nursesÕ autonomy to use
their knowledge and expert judgement in providing
patient care.
Manojlovich and Laschinger (2002) and Laschinger
et al. (2001a) found strong intercorrelations between
structural and psychological empowerment. The studies
supported the conceptualization of empowerment pro-
vided by Spreitzer (1995) that psychological empower-
ment is an outcome of structural empowerment and is
an intervening mechanism between structural work
conditions and important organizational outcomes,
including job satisfaction.
Critical social empowerment
The Critical social empowerment theory originated in
the Frankfurt School in 1920s Germany (Kuokkanen &
Leino-Kilpi 2000). It theorises that certain groups are in
a subordinated position. Kuhse (1997) sees social
institutions as frequently the bastions of unequal dis-
tribution of power and privilege, with medicine and
nursing as examples. Kuhse writes that history has
Ôburdened nurses with a number of metaphors that may
well have inhibited their self-perception as autonomous
and self-determining professionalsÕ (p. 16). During
training, nurses were exhorted to defer to doctors
(Kuhse 1997):
ÔLoyalty is the first essential…your training and
the lectures you receive are given so that you can
intelligently cooperate with the doctor in the
26 ª 2009 The Authors. Journal compilation ª 2009 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 24–34
treatment of the patient. The little knowledge you
will have gained during your years in hospital in
no way fits you to diagnose disease or to prescribe
treatment, nor does it place you in a position to
criticize the doctor or his methods. Accord to him
always that deference and respect which is his dueÕ
(Burbridge 1950, in: Kuhse 1997, p. 25).
Lewis and Urmston (2000) note the wide acceptance
of nurse subservience to medical staff and administra-
tors. Judge Clark inquiring into Dr NearyÕs practice of
excessive use of caesarian hysterectomy reported that,
ÔObedience was part and parcel of the training of nurses
…Õ (Government of Ireland 2006, p. 187).
Lukes (2005) describes power as three dimensional:
overt, covert and institutionalized. Institutionalized
power is at its most effective when least observable and
is maintained not just by individually chosen acts, but
also, most importantly, by the socially structured and
culturally patterned behaviour of groups, and practices
of institutions, which may be manifested by individualsÕ
inaction. This is the Ôthird dimensionÕ of power and is
the power Ôto prevent people, to whatever degree, from
having grievances by shaping their perceptions, cogni-
tions and preferences in such a way that they accept
their role in the existing order of thingsÕ (p. 11). The
consequences for those in subordinated positions is they
are led to acquire beliefs and form desires that result in
their consenting or adapting to being dominated, to see
their condition as ÔnaturalÕ and even to value it, in
coercive and non-coercive settings.
Practice development has drawn on critical social
science in the use of emancipatory change processes
since the 1970s. Emancipatory practice development is
concerned with the medium of power and the social
system. Facilitators aim to help practitioners to become
aware of unspoken aspects of their practice and the
organizational systems constraining them. Empower-
ment of staff is deliberate and responsibility for action
rests with the practitioners themselves (Manley & Mc-
Cormack 2005).
The conceptualization of critical social empowerment
is at an early stage of development (Kuokkanen & Le-
ino-Kilpi 2000). Fulton (1997) undertook a small
qualitative study from this social perspective. The cat-
egory Ôrelationship with multidisciplinary teamÕ in-
cluded the themes of medical power, autonomy of the
medical staff and the team.
Wicks (1998) conducted an ethnographic field study
into the work of nurses and doctors in a British teaching
hospital. It examined impediments to the autonomy of
nurses which inhibited their bedside healing. Wicks

(1998, p. 91) concluded that Ôpower is ever present
within health care settings. It is evident in the way
people walk, in the way they communicate, in who gets
recognized as having a presence and who gets ignoredÕ
and that this contravenes modern management and the
teamwork theory.
Laschinger and Finegan (2005a) in a survey of 273
medical-surgical and critical care nurses found they
perceived that physicians and managers did not respect
either them or their work. This was evidenced in the
way that organizational decisions were delivered with-
out prior consultation. ÔHistorical legacyÕ, described as
the historical development of the nursing profession and
its position relative to other professions and social
structures, emerged as a key theme in the national Irish
empowerment study, supporting the relevance of the
critical social perspective to nursing (DOH & C/DCU
2003).
Empowerment and job satisfaction
A fundamental aim of empowerment is for team
members to stretch themselves to reach their full po-
tential. This results in job satisfaction. Job satisfaction
is important. Satisfied nurses and midwives are more
likely to rise to the challenge of organizational
restructuring and patientsÕ perceptions of the quality of
nursing care are related to nurse satisfaction (Mano-
jlovich & Laschinger 2002).
Studies (DOH & C/DCU 2003, Sarmiento et al.
2004) have found structural empowerment to be
strongly correlated with job satisfaction. Manojlovich
and Laschinger (2002) found that structural and psy-
chological empowerment predicted 38% of the variance
in job satisfaction, with structural empowerment ac-
counting for 29.5% of the variance by itself.
Hypotheses
There is evidence for the link between psychological
and structural empowerment and job satisfaction.
Critical social empowerment should arguably also lead
to psychological empowerment and job satisfaction.
Based on the three theoretical perspectives of
empowerment and the preceding literature review, the
following hypotheses were proposed:
• Structural and critical social empowerment are posi-
tively related to psychological empowerment.
• Access to structural, psychological and critical social
sources of empowerment would in turn have a posi-
tive effect on job satisfaction.
ª 2009 The Authors. Journal compilation ª 2009 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 24–34
Job satisfaction in nursing and midwifery settings
Method
A descriptive, non-experimental, relational survey de-
sign, defined by Robson (2002) as measuring the rela-
tionship between two or more variables, was used. This
method was chosen as it is suitable in situations where
the aspects of interest are not amenable to changes by
the researcher.
Sample
After ethical approval, all nurses and midwives who
had participated in the 3-day Leading an Empowered
Organization (LEO) Programme in the Mid-West re-
gion and one large Dublin teaching hospital in the last
4 years were surveyed. RobsonÕs (2002) recommenda-
tions regarding multiple contacts were used to maxi-
mize the return rate.
Instruments
Four instruments were used to measure the study vari-
ables. All items were rated on Likert scales.
Structural empowerment
Structural empowerment was measured by Conditions
of Work Effectiveness Questionnaire (CWEQ-11)
developed by Laschinger et al. (2001a). CWEQ-11
(Laschinger 2004) is a 19-item scale measuring perceived
access to the six components of structural empowerment
described by Kanter (opportunity, information, support,
resources, formal and informal power). Each subscale
has three items. The construct validity of the CWEQ-11
was substantiated in a confirmatory factor analysis that
revealed a good fit of the hypothesized factor structure
(x2 = 279, RMSEA = 0.054) (Laschinger et al. 2001a).
Cronbach alpha reliability ranged from 0.68 to 0.88 in
this study. A correlation coefficient above 0.7 is consid-
ered to offer reasonable reliability for research purposes
(Robson 2002).
Psychological empowerment
The 12-item Psychological Empowerment Scale devel-
oped by Spreitzer (1995) measuring the four compo-
nents of psychological empowerment, meaningful
work, competence, autonomy and impact, in a work
context was used. Each subscale has three items.
Spreitzer (1995) established evidence of convergent and
divergent validity of the four dimensions and reported
acceptable reliability levels (range: 0.62–0.72). Lasch-
27
M. Casey et al.
inger et al. (2001a) further validated the proposed fac-
tor structure in a Confirmatory Factor Analysis
(x2 = 117, RMSEA = 0.059). Alpha reliability in this
study was >0.82.
Critical social empowerment
The researcher added a four-item scale to measure critical
social empowerment. These four items elicited respon-
dentsÕ perception about whether they are viewed as pro-
fessionals by members of the multi-disciplinary team, and
whether they are involved in decisions that affect them-
selves, the organization and the multidisciplinary team.
Each item represented a statement with which respon-
dents were required to indicate their level of agreement.
These items were derived from the literature reviewed for
the study. The authors of the national study (DOH & C/
DCU 2003) had included two items related to critical
social empowerment. These items were Ôbeing listened to
by members of the multidisciplinary teamÕ and Ôbeing
recognized as a professional by the medical professionÕ.
The need for greater involvement of nursing and mid-
wifery in organizational decision-making was identified
by the Commission on Nursing (Government of Ireland
1998). The need to involve employees in decisions that
affect their working life has been highlighted in successive
staff surveys by the Healthcare Commission (2006). This
four-item scale was subjected to a factor analysis and the
results suggested the items loaded appropriately, with
only one main factor explaining 63% of the variance and
all of the variables had a loading ‡0.66. In this study,
CronbachÕs alpha reliability was 0.80.
Job satisfaction
Job satisfaction was measured using a 17-item scale
(Warr et al. 1979). The scale was chosen because some
of the items are related to empowerment. These are:
• freedom to choose your own method of working (item
2);
• recognition you get for good work (item 4);
• opportunity to use your abilities (item 8);
• attention paid to suggestions you make (item 12);
• amount of challenge in your job (item 16) and;
• the way your organization is managed (item 11).
In this study the CronbachÕs alpha reliability was 0.88.
Data analysis
Descriptive and inferential statistical analyses were
performed using the Statistical Package for Social
28 ª 2009 The Authors. Journal compilation ª 2009 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 24–34
Table 3
Profile of the sample respondents
Number Per cent
Staff nurse/midwife/public 50 19.1
health nurse
Clinical nurse/midwife manager 120 50.0
Clinical nurse/midwife 36 15.0
specialist/advanced nurse practitioner
Assistant director of nursing/midwifery 31 13.3
Director of nursing/midwifery 3 1.3
Tutors/others 3 1.3
Total 244 100
Sciences Programme (S P S S Version 15; SPSS Inc., Chi-
cago, IL, USA). Regression analysis and SpearmanÕs
rank correlation analysis was used to test the study
hypotheses. Measures of correlation were used to
identify the strength and direction of relationships be-
tween variables. After calculation of correlation coeffi-
cients, regression analysis was carried out to estimate
the variance in job satisfaction that could be explained
by empowerment. Appropriate scales were entered into
a regression model in a stepwise fashion. This allowed
testing for prediction in the outcome variables to test
the hypotheses proposed.
A total of 306 were asked to participate in the study
and 244 usable questionnaires were returned, a re-
sponse rate of 80% (Table 3).
Eighty-four per cent worked in hospitals. Only seven
out of the 37 managers at senior grade had previously
undertaken another leadership programme and this was
either at certificate level or a module as part of a
management programme. Thirteen respondents were
male.
Descriptive statistics
The mean values and standard deviation (SD) of the
major study variables are presented in Tables 4–7.
Structural empowerment
Nurses perceived their work environment to be some-
what empowering. The finding that participants
perceived that they had most access to opportunities for
challenging work and information and least access to
support and resources is consistent with findings in
other nursing populations including Patrick and Las-
chinger (2006) and Sarmiento et al. (2004).
Some revealing individual items from these scales
were that only 28% agreed they have specific infor-
mation about things they do well. In the scale measur-
ing formal power only 20% agreed they have rewards
for innovation on the job.
 Job satisfaction in nursing and midwifery settings

Table 4 Table 7
Mean values and standard deviation (SD) of structural empowerment Mean values, SD of items of job satisfaction

Scale Range* Mean SD

range* Mean SD
Amount of challenge in your job (item 16) 1–7 5.51 1.25
Total structural empowerment 6–30 19.27 Opportunity to use your abilities (item 8) 4.96 1.40
Opportunity 1–5 4.12 0.86 Freedom to choose your own method of 5.03 1.35
Information 1–5 3.16 1.09 working (item 2)
Support 1–5 2.82 1.15 Recognition you get for good work (item 4) 4.08 1.70
Resources 1–5 2.69 1.13 Attention paid to suggestions you make 4.29 1.60
Formal power 1–5 2.79 1.01 (item 12)
Rewards for innovation 2.50 1.09 The way your organization is managed 3.88 1.65
Flexibility in job 3.01 1.03 (item 11)
Visibility of work related activities 2.87 0.92
Informal power 1–5 3.69 1.09 *Scale range = 1–7: 1 = low, 7 = high.
Collaborating on patient care 3.61 1.18
with doctors
agreed they have significant autonomy in determining
Being sought by peers 4.02 0.93
Seeking out ideas from other 3.44 1.17 how they do their job whereas 65% agreed their impact
professionals on what happens in their department is large.
Respondents reported a moderate level of critical
*Scale range = 1–5: 1 = low, 5 = high.
 Total structural empowerment score range from 6 to 30, with 14 to social empowerment. Seventy-three per cent perceived
22 indicating moderate empowerment (Laschinger 2005). they have a sense that they are seen by other disciplines
as a professional; falling to 57% who perceived they
Table 5 were involved and listened to about decisions that affect
Mean values, SD of psychological empowerment them whereas only 42% felt they were involved and
Scale listened to about decisions affecting the organization.
range* Mean SD Respondents reported a moderate level of job satis-
faction. Consistent with the opportunity sub-scale, 84%
Total psychological empowerment 4–20 16.29 1.53
Meaningful work 1–5 4.53 0.51 were satisfied with the amount of challenge in their jobs
Competence 1–5 4.41 0.54 and 75% were satisfied with the opportunity to use
Autonomy 1–5 3.90 0.82 their abilities. Regarding autonomy, 74% were satisfied
Impact 1–5 3.44 0.99
with the freedom to choose their own method of
*Scale range = 1–5: 1 = low, 5 = high. working. Related to formal power, only 50% were
 Total psychological empowerment score range from 4 to 20, with satisfied with the recognition they get for good work.
16.29 indicating a moderately high level. Associated with critical social empowerment, 56%
were satisfied with the attention paid to suggestions
Table 6 they make whereas only 43% were satisfied with the
Mean values, SD of critical social empowerment
way their organization is managed.
Range* Mean SD Few demographic variables were related to empow-
Total critical social empowerment 1–5 3.48 0.96
erment.
Seen by other disciplines 3.81 0.82 Mean scores for opportunity and information rose
as a professional with grade. Clinical nurse specialists (CNSs) and ad-
Involved and listened to about 3.47 0.98
vanced nurse practitioners (ANPs) had significantly
decisions that affect me
Involved and listened to about 3.17 1.02 higher levels of informal power (median 3.92, Mann–
decisions that affect the organization Whitney £ 0.01) compared with other grades,
Effectively involved in multi-disciplinary 3.48 1.04 including senior nurse managers (mean = 3.40).
decision-making activities
There were also significant differences rising with
*Scale range = 1–5: 1 = low, 5 = high. grade for the impact sub-scale of the psychological
empowerment scale and organizational decision-mak-
Nurses and midwives reported a moderately high le- ing.
vel of psychological empowerment, especially in rela-
tion to meaning (98% of respondents agreed their work
Hypothesis 1
is very important to them) and competence (97%
perceived themselves to be competent). Respondents Regression analysis permitted the estimation of variance
reported lower levels for autonomy and impact: 78% in psychological empowerment explained by structural

ª 2009 The Authors. Journal compilation ª 2009 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 24–34 29
M. Casey et al.

Figure 1
Estimation of variance in psychologi-
cal empowerment and job satisfaction
explained by critical social empower-
ment.

and critical social empowerment hypothesized from the
literature review. Structural and critical social empow-
erment together predicted 35% of the variance in psy-
chological empowerment (R2 = 0.354, P £ 0.0005).
Critical social empowerment was the stronger predic-
tor, accounting for 29.9% of the variance in psycho-
logical empowerment on its own (R2 = 0.299,
P £ 0.0001) while structural empowerment predicted
a further 5.5% (R2 = 0.055, P £ 0.0001) of the
variance in psychological empowerment (Figure 1).
Collinearity statistical analysis to rule out multicollin-
earity revealed a tolerance value of 0.75. This validates
that the two predictor variables are not too strongly
related to one another, as the tolerance value is >0.6
(Muijs 2004).
Hypothesis 2
The combination of structural, psychological and criti-
cal social empowerment predicted 45% of the variance
in job satisfaction (R2 = 0.455, P £ 0.0005).
Table 8
Correlations among scales, subscales and individual items
All three aspects were significant independent pre-
dictors of perceived job satisfaction with critical social
empowerment being the strongest predictor, accounting
for 35% of the variance in job satisfaction on its own
(R2 = 0.351, P £ 0.0001). Psychological empower-
ment predicted a further 7.1% (R2 = 0.071, P £
0.0001) and structural empowerment contributed a
further 3.3% of the variance (R2 = 0.033, P £ 0.002)
(Figure 1).
Collinearity statistical analysis revealed a tolerance
value of 0.73. Additional SpearmanÕs correlational
analyses revealed significant positive relationships
(Table 8).
Discussion and conclusions
The present study suggests that critical social empow-
erment is a key factor in both psychological empower-
ment and job satisfaction. Item 12 Ôattention paid to
suggestions you makeÕ and job satisfaction were
strongly correlated and critical social empowerment

Variable SE PE CSE JS Impact Autonomy

Support 0.64 0.36 0.48 0.51 0.31 0.28

Formal power 0.59 0.45 0.58 0.59 0.49 0.39
Informal power 0.48 0.38 0.24 0.23 0.28 0.30
Freedom to choose own method of working (item 2) 0.26 0.52 0.30 0.57 0.44 0.56
The recognition you get for good work (item 4) 0.38 0.32 0.45 0.74 0.31 0.35
Attention paid to suggestions you make (item 12) 0.41 0.49 0.61 0.77 0.54 0.42
Impact 0.51 0.78 0.59 0.50 1.00 0.52
Autonomy 0.42 0.80 0.49 0.57 0.52 1.00

P ‡ 0.01.
SE, structural empowerment; PE, psychological empowerment; CSE, critical social empowerment; JS, job satisfaction.

30 ª 2009 The Authors. Journal compilation ª 2009 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 24–34

accounted for 35% of the variance in job satisfaction on
its own. Yet only 42% of respondents felt that they
were involved and listened to about decisions that affect
the organization. One of the characteristics of magnet
hospitals is that nurses report they participate in policy
decisions and their contributions to healthcare out-
comes are valued (Aiken et al. 2000). The Commission
on Nursing (Government of Ireland 1998) recom-
mended greater inclusion of nursing in strategic deci-
sion-making, including financial and human resource
management. Carney (2004) found Directors of Nursing
in Ireland perceived they were frequently excluded from
strategy development. In a survey of the 152 Primary
Care Trusts in England, the Royal College of Nursing
(2009) found that 20% did not have an executive nursing
director with voting rights on the board. Apker (2002)
reported that managers experience high levels of role
stress as a result of a lack of participation in decision-
making and when their opinions are not valued.
Klakovich (1996) suggests that what may be lacking for
nursing empowerment are strategies to provide oppor-
tunities for nurses to co-create a shared vision and thus to
experience true ownership of results. Involvement of
middle management in strategy development is impor-
tant as this increases the likelihood that middle managersÕ
initiatives will be in line with top managementÕs concept
of corporate strategy (Carney 2004).
Only seven of the senior nurse managers had previ-
ously undertaken another leadership programme.
Competence in strategic planning and influencing
organizations is important for nurse leaders and pur-
suing advanced degrees in administration prepares for
effective leadership (Murphy 2005). Carney (2004)
points out that directors and assistant directors of
nursing must also be willing to delegate operational
issues to empower first-line managers and create time
for strategic management; and demonstrate a colla-
borative mindset in order to benefit health service
outcomes.
Nurses and midwives reported, albeit to a lesser ex-
tent, similar deficits in involvement in decisions that
affect themselves (43% disagreed they were involved)
and the multi-disciplinary team (40% disagreed).
A significant number (27%) disagreed or were unsure
that they were seen by other disciplines as a profes-
sional. Laschinger and Finegan (2005a) report that the
Canadian Nursing Advisory Committee highlighted the
fact that nurses feel doctors and administrators do not
respect them. This shows in the way important orga-
nizational decisions are communicated and the failure
to address concerns expressed by nurses about their
implications.
ª 2009 The Authors. Journal compilation ª 2009 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 24–34
Job satisfaction in nursing and midwifery settings
Structural empowerment
Sixty-nine per cent of respondents reported between
ÔnoneÕ and ÔsomeÕ information about the values of top
management. Middle-level and senior nurse and
midwife managers had significantly higher mean scores
(3.90) for information compared with clinical nurse
managers (3.29), clinical nurse specialists (2.60) and
staff nurses (2.76) indicating the need for better cas-
cading of information.
The strong relationship between the sub-scale mea-
suring support and job satisfaction suggests that when
nurses and midwives receive positive support they feel
valued by the organization. Similar results were
reported by Patrick and Laschinger (2006) and Sarmi-
ento et al. (2004). Yet, the majority of respondents
(over 70%) indicated they received little feedback or
problem-solving advice. Support has been identified by
Ewens (2003) as also important for innovation in
professional role development.
The structural component rated as having the most
deficits for work effectiveness was lack of resources.
Reasonable workloads and time (Kanter 1993) are
essential empowerment resources. Time constraints
have also been identified as significant barriers to
effective communication (Hancock et al. 2005) and
creativity (Quinn & Spreitzer 1997).
Within formal power, an important finding with
implications for the current emphasis on reforming
health services is the perception held by 82% of
respondents that there is little or no reward for
innovative work. Lack of recognition has been linked
with cynicism (Thomas & Dunkerley 1999) and
absenteeism and decreased performance (Eisenberger
et al. 1990).
The finding that CNSs/ANPs have higher levels of
informal power than other nurses and midwives is
similar to findings by Almost and Laschinger (2002).
Kanter (1993) believes work structures, such as teams,
empower by fostering opportunities to learn, support
and share resources. Klakovich (1996) emphazies access
to informal power and collaborative working for
improved patient outcomes. Baggs et al. (1992)
demonstrate a link between nurse–physician collabo-
ration and mortality in intensive care units.
Psychological empowerment
Virtually all participants perceive they are doing
meaningful work competently. Perceived value and
meaning in work enables calculated risks that improve
outcomes (Creative Healthcare Management 2003).
31
M. Casey et al.
Laschinger and Finegan (2005b) emphasize the
importance placed on autonomy by professional nurses.
Yet respondents reported deficits in autonomy. The
significant relationships between autonomy and
empowerment and job satisfaction were similar to
Laschinger and FineganÕs (2005b), who point out this is
not surprising given the importance of professional
decision-making in patient-centred care.
Of the four components of psychological empower-
ment, impact is the component respondents identified
the most deficits with; as many as 44% disagreed or
were unsure they have significant influence over
departmental activity. Employers market nursing as a
career where people Ôcan make a differenceÕ. Therefore,
the strong correlations between impact, empowerment
and job satisfaction are not surprising and are similar to
the findings by Manojlovich and Laschinger (2002).
Limitations
This studyÕs findings must be interpreted with caution
given the cross-sectional nature of the design, giving
only a measure of participantsÕ experience at one point
in time (Robson 2002). The use of self-report, cross-
sectional data has the limitation of being subject to
method variance. This is more of a problem with single
item or poorly designed scales and less so in well-de-
signed and multi-item scales. The tools used to measure
structural and psychological empowerment and job
satisfaction had demonstrable reliability and validity
and this would mitigate the problems to some degree.
The four-item researcher designed scale to measure
critical social empowerment was developed for this
study and would need further testing.
Implications
This research expands our understanding of empow-
erment through including a third dimension, the critical
social perspective. The insight of critical social
empowerment is that nursing belongs to the class of
social groups whose position is culturally subordinated.
Critical social empowerment shows that to reach their
potential organizational contribution, nurses and mid-
wives should have an equal voice in decision-making
with doctors and managers. This study found critical
data to suggest that critical social empowerment is not
a naive aspiration. Over 97% of respondents report
their competence and the meaning and value they find
in their work. There is huge capital here. But unless
organizational leaders facilitate nurses and midwives to
have a greater voice in organizational decision-making
32 ª 2009 The Authors. Journal compilation ª 2009 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 24–34
they will not achieve the engaged, innovative and
productive staff they say they want. Clinical gover-
nance and decentralized management practices enable
managers to empower clinical staff through fewer
hierarchical layers, thus enhancing involvement in
decision-making, ownership of the vision and sharing
of information. Healthcare organizations must estab-
lish frameworks for the effective involvement of nurses
and midwives in strategic decision-making, for exam-
ple, by nominating them for membership on senior
committees.
Nurse managers themselves must also seek to be in-
cluded in organizational decision-making to ensure
their voice is heard at an organizational level and to
obtain information needed by staff for best patient
healthcare. Nurse and midwife managers, especially at a
senior level, need to realize and be competent in their
vital role of influencing the organization to benefit
healthcare outcomes for patients (Sieloff 2004). Making
time for this activity also requires the appropriate del-
egation of operational management to frontline staff.
This, in turn, facilitates empowerment of frontline staff
and retention of younger generations of nurses (Wilson
et al. 2008).
Within nursing and midwifery, immediate line man-
agers play a critical role in modifying work environ-
ments to increase all three dimensions of empowerment.
From a critical social perspective, line managers must
consult staff about changes that affect them, take their
suggestions seriously and show that their decisions have
been influenced by staff suggestions. They must skill-
fully communicate the organizational priorities to their
staff and trust their staff with the authority and
responsibility to translate these priorities into practice.
To provide structural empowerment, they can
implement regular scheduled open forums to share vital
information openly and honestly so as to empower
nurses and midwives. Providing support and regular
feedback to nurses and midwives, and giving opportu-
nities to discuss concerns is crucial. Professional
supervision is one structured framework to provide
support, learning and accountability. Implementing
systematic systems to determine staffing levels and skill
mix will help to empower staff by ensuring appropriate
resources. This includes appropriate utilization of
health care assistants and including time needed for new
activities such as expanded roles, clinical audit, pro-
fessional development, supervision and preceptorship
for student nurses.
Nurse and midwife managers can increase access to
informal power and involvement in multidisciplinary
working by continuing to establish further CNS/ANP
 Job satisfaction in nursing and midwifery settings

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