Nursing empowerment and job satisfaction: an integrative review according the Structural Theory Empoderamiento y satisfacción profesional en Enfermería: una revisión integradora, según la Teoría Estructural

Contexto: Poder é um conceito central para o desenvolvimento profissional, sendo uma das características do processo de tomada de decisões, em conjunto com o recurso a um corpo único de conhecimentos. Através do processo de Empoderamento o profissional está apto a influenciar o outro sendo considerado um elemento chave nas organizações contemporâneas. Objetivos: Estudar a relação existente entre Empoderamento e Satisfação Profissional, numa primeira análise, do ponto de vista estrutural. Metodologia: Procedeu-se a uma revisão integrativa da literatura (2005-2011) de artigos das bases de dados Medline® e CINAHL, de acordo com a metodologia PICOD. Resultados: Foram identificados 22 artigos, provenientes de contextos variados, sendo a maioria efetuados no continente americano (64%) e asiático (32%). Conclusão: Apesar desta diversidade, constata-se a clara relação expressa entre Empoderamento e Satisfação Profissional, sendo diretamente proporcionais. Salienta-se ainda a influência da idade, contexto de desempenho profissional, formação académica e qualificação profissional na percepção de Empoderamento. Dado, da nossa pesquisa, não ter sido possível localizar estudos conduzidos em Portugal, importa o desenvolvimento desta temática.


Introduction
Nursing is currently undergoing structural and organisational changes (Serrano, Costa, & Costa, 2011), and there are those who consider Nursing as the profession with the lowest prestige within the health system (Fletcher, 2007).In parallel, and in line with Serrano et al. (2011), the process of construction of the discipline and its evolution (from a functionalist approach to a reflexive approach) launched the debate and led to some fruitful discussions among peers.Thus, the interest emerged to study the phenomenon of Nursing Empowerment, given its impact on several variables influencing Nursing, in particular job satisfaction.As in other disciplines, Empowerment plays a central role in Nursing (Stewart, McNulty, Griffin, & Fitzpatrick, 2010).Thus, defining Empowerment might seem an arduous task, as it is a complex issue influenced by many factors.Although there are numerous definitions of Empowerment in the literature on management, the central idea is related to the acquisition of power (as a result of the work conditions offered by the organisation) by the individuals so as to effectively accomplish their work (Laschinger, Gilbert, Smith, & Leslie, 2010).There are two theories of Empowerment regarding organisational environment: structural and psychological empowerment.According to Laschinger, Finegan, Shamian, and Wilk (2001), struc tural empower ment refers to the presence or absence of empowering conditions in the workplace.Psychological empowerment is related to a sense of motivation towards the organisational environment, based on the dimensions of meaning, competence, selfdetermination, and impact (Laschinger et al., 2010).However, assuming that the subjectivity resulting from the complexity of this issue could be present in its analysis, Laschinger et al. (2001) show that it will be possible to measure this concept, from a structural perspective, based on studies by Kanter in 1977.This author argues that the social structures of professional organisations influence the attitudes and behaviours of the employees who react rationally to the situations in which they find themselves, anticipating that power is the ability to mobilise resources to secure desired ends.Power in an organisation derives from the access to the following sources found in the formal and informal systems (Laschinger, & Finegan, 2005a): (a) information, technical and scientific knowledge necessary to accomplish work, congruent with the individual and organisational values; b) support, relationship with peers and senior staff and the ability to take risks, without going through the several layers of approval; c) resources, ability to influence the acquisition of time, material and human resources necessary to accomplish work and the organisational objectives; d) opportunity, opportunities to increase the knowledge and skills necessary to accomplish work (McDonald, Tullai-McGuinness, Madigan, & Shively, 2010).Serrano et al. (2011) advise that, in a skills analysis, it is imperative to refer to the relationships between the professionals and the institution, given the mutualistic relationship established.Thus, it is important to create conditions to optimise work and ensure access to the abovementioned structured, which should be a responsibility of senior managers.Employees feel empowered if they feel that their organisational environment provides them access to these structures, resulting in increased levels of organisational commitment, autonomy, and selfefficacy (Laschinger & Finegan, 2005b).The Conditions of Work Effectiveness Questionnaire (CWEQ) was developed by Chandler in 1986 and from it derived the CWEQ-II (Laschinger et al., 2001), which consists of 19 items (on a scale of 1 to 5) intended to measure six components described by Kanter (opportunity, information, support, resources, formal power, and informal power) and an «extra» 2-item scale (global empowerment, for validation purposes).Scores range from 6 to 30: scores ranging from 6 to 13 represent low levels of empowerment, 14 to 22 moderate levels of empowerment, and 23 to 30 high levels of empowerment (Laschinger et al., 2001).Significant data may be obtained from analysing the results obtained with the abovementioned instruments, since access to these structures leads to a higher organisational commitment and sense of autonomy (Laschinger et al., 2001).A positive relationship was found between Empowerment, Job Satisfaction, and commitment to organisational goals (Laschinger & Finegan, 2005a;Ning, Zhong, Libo, & Qiujie, 2009).An integrative literature review was conducted to assess and synthesise the knowledge produced and published in this area.It will focus on the structural perspective so as to identify the relationship between empowerment and job satisfaction.
January 2011.To restrict the terms (according to MeSH descriptors), the following Boolean expression was used: (empowerment OR autonomy) AND (nurs*) AND (Job satisfaction OR work satisfaction OR intent to leave).The review focused on articles published between 2005 and 2011 in MEDLINE® and CINAHL databases (Table 2).The terms autonomy and intent to leave were chosen for being complementary to the main search terms.This study followed the steps recommended by the Joanna Briggs Institute (JBI, 2011): formulation of a research question, definition of the literature selection methods, description of the data extraction procedure, evaluation of the results according to their relevance and validity, data extraction, and synthesis of the conclusions.The research question follows the PICOD methodology (JBI, 2011): participants, intervention, context, outcomes, and design/type of study, as shown in Table 1.
Thus, this study aims to characterise the relationship between Empowerment and job satisfaction based on the Structural Theory through studies published between 2005 and 2011 in the databases of selected indexed journals.To accomplish this objective, we intend to answer the following research question: «What is the relationship between professional empowerment and job satisfaction in Nursing from the structural point of view?»The results obtained may inform future studies and serve as basis for the development of the clinical practice and, consequently, the discipline itself, with a potential to influence policies (Ahmad & Oranye, 2010;Chang, Liu, & Yen, 2008;Li, Chen, & Kuo, 2008;Laschinger, Leiter, Day, & Gilin, 2009).

Methodological Procedures of Integrative Review
The search for articles written in Portuguese and English was carried out between December 2010 and To refine the search, the area of interest was restricted to "Nursing" and the main subject to "Professional Autonomy" or "Empowerment" or "Job Satisfaction", as shown in Table 2.The following inclusion criteria were applied: studies in which the sample was composed of Nurses, that established an association between Empowerment and Job Satisfaction, that clearly identified the different methodological steps, that used the Conditions of Work Effectiveness Questionnaire II (CWEQ-II), and that addressed the Structural Theory.
Those studies that did not address Empowerment (a factor outlined above), those whose methodological steps were ambiguous, those whose sample was not exclusively composed of Nurses, duplicate articles, historical articles, opinion articles, legislation, interviews, editorials and meeting minutes were excluded.The articles were selected and excluded based on JBI guidelines (2011) and the steps recommended by Gálvez and Moreno (2000).It was based on these documents that the quality of the different studies was analysed in terms of the adequate literature review, the studies selected, the methodology (study design and clarity of the research question), the data synthesis, and the summary of findings.In order to ensure data quality, these steps were validated by another researcher.These data were extracted into a database using MS Excel 2011, which included the following information: sample (total and response rate), gender, age, length of service (total and in the current service), CWEQ-II (total score and scores of the subscales), and geographical location and context of the study.

Results and Interpretation
Based on this strategy, after reading the title, the abstract and the keywords, 72 articles were selected.
After full-text analysis, 50 articles that did not meet the inclusion criteria were excluded.A systematic review (Wagner et al., 2010) was also excluded from this study because its target of analysis and, consequently, the search criteria was the relationship between structural and psychological empowerment, thus omitting relevant studies for this analysis.The corpus of analysis consisted of 22 articles, as shown in Table 3. Table 3 shows that most studies were conducted in North America (United States of America and Canada), followed by Asia (China and Malaysia), and Europe (Italy, Ireland, and the United Kingdom).
All of the analysed articles follow a quantitative approach, use the CWEQ-II, and describe the methodological steps.There are some limitations, particularly regarding sample size and type of sampling (namely in response rates below 60%).In those studies, including information on these data, participants had a mean age of 39.5 years and between 66.7% and 100% of female participants, as shown in Table 4.  Using the CWEQ-II, researchers measured participants' level of perceived empowerment and job satisfaction.Table 5 shows data from the different studies concerning the subscales previously listed and the predictive value of structural empowerment.Data resulting from the different CWEQ-II subscales were also identified, whenever possible.Data were totally missing or incomplete in five and two of the studies, respectively.
Table 5 Results of the CWEQ-II and the subscales These results differ from the Portuguese reality, particularly regarding gender and age (Ordem dos Enfermeiros, 2012).In the analysed studies, the percentage of women is slightly higher than in the Portuguese reality, as well as the participants' mean age.Considering that the studied populations have their own characteristics and assuming that Empowerment relies on the conditions offered by the organisation which, in turn, depends on the conditions of the surrounding environment (Laschinger et al., 2001), these results may not be generalised to the Portuguese population.
In the studies that presented the scale scores, it was observed that most nurses had moderate levels of empowerment (n=17.94%),whereas only 6% had high levels of empowerment (n=1).
In the study by Ahmad and Oranye (2010) on the differences in Empowerment, Job Satisfaction, and Commitment to the Organisation in two distinct realities (England and Malaysia), a potential relationship between demographic data and the perception of empowerment was found: in distinct realities, the major determinants of empowerment may be different.Thus, in the English hospital, the determinants of empowerment were work position and flexibility of the work system, whereas in the Malaysian hospital, age and level of education were the main determinants.
As it is generally agreed that empowerment derives from the combination of access to several factors, the differences in scores between the different subscales that may be predictors of organisational status in the analysed realities should be discussed.In the analysis of the CWEQ-II subscales, the highest score was found in the Opportunity subscale (by analysing the first four factors) and the lowest score in the Access to resources subscale, with the exception of the Asian studies.In general, Informal Power scores are higher than Formal Power scores.These data are consistent with the studies by Casey et al. ( 2010), Davies et al. (2006), Fitzpatrick et al. (2010), Laschinger (2008), Laschinger and Finegan (2005b), McDonald et al. (2010), Stewart et al. (2010), and Zumerhly et al. (2009), whose participants attach greater importance to the concept underlying the Opportunity subscale.
In the studies by Cai and Zhou (2009), Li et al. (2008), and Ning et al. (2009), the highest score was not found in the opportunity subscale.The common aspects to these studies were that they were carried out in Asia with an exclusively female sample.These differences are explained by the social, cultural, and political differences, with the consequent differences in Education, as well as in the dominant gender in the profession when compared with the western cultures.

Academic qualifications and Professional certification
With regard to certification, Fitzpatrick et al. (2010), in a study with Intensive Care Nurses, concluded that the certification by recognised bodies may lead to a higher perception of empowerment.Zumerhly et al. (2009) suggest that the level of education may be a predictor of empowerment.Cai et al. (2011) argue

Job Empowerment and Job Satisfaction
The positive relationship between Empowerment and Job Satisfaction is clearly visible in the analysed studies.Thus, a positive perception of Empowerment is a predictor of Job Satisfaction (Cai, & Zhou, 2009;Chang et al., 2010;Davies et al., 2006;Laschinger et al., 2007;Laschinger, 2008;Laschinger, Laschinger et al., 2009;Laschinger, & Finegan, 2005b;Lautizi et al., 2009;Leiter et al., 2009;Li et al., 2008;McDonald et al., 2010;Ning et al., 2009;Stewart et al., 2010;Zurmehly et al., 2009).In other words, a direct and positive relationship between empowerment and job satisfaction is clearly shown, as had been advanced by Laschinger et al. (2001).Although this relationship is not clearly established in the other analysed studies, its presence can be inferred.

Context of job performance
In this analysis, we need to address the factors that may influence the results or inform future studies.
In a study carried out in China with School Health Nurses, Chang et al. (2010) underline that the nurses' perception of empowerment may derive from the fact that they are not under medical supervision.
The only predictor of a high perception of empowerment was found in the study by Stewart et al. (2010).These researchers conducted a study with Advanced Practice Nurses in the State of Connecticut (USA), with at least one year of experience and aged between 41 and 50 years.A response rate of 16% was obtained.This reality is very different from the one found in some of the analysed studies, and for this reason, in line with Stewart et al. (2010), the results should be limited to the sample under study as it is not representative of the whole population and it cannot be generalised to different geographical areas.
In contrast, In Italy, in the only study with Mental Health Nurses, the Nurses reported lower scores in the access to the opportunity to learn and grow and higher scores in the access to resources.This fact may explain the concern with the technical aspects and job needs over the relational and educational aspects (Lautizi et al., 2009).

Demography and cultural context
In a study involving professionals from different areas (hospital and non-hospital care), McDonald et al. (2010) showed no significant relationship between demographic data and perception of Thus, the creation of organisational environments in which nurses can feel empowered triggers feelings of job satisfaction and organisational commitment in nurses, leading to high levels of performance (care provision or other).Thus, nurses will feel more capable of performing their tasks efficiently, reinforcing the idea of remaining in the organisation.
In our research, we found that this phenomenon is understudied in the Portuguese reality.So, it is a challenge to assess the nurses' perception of empowerment and identify the main factors promoting empowerment so that we can optimise the practice and benefit from potential advantages.

Conclusion
These results reinforce the proposal of the structural theory: the access to the structures that promote empowerment (opportunity, information, resources, and support) provides the Nurses with the necessary tools to perceive levels of autonomy capable of increasing job satisfaction, the commitment to the organisational objectives, self-efficacy, productivity, and effectiveness.
Of an initial selection of 72 articles, 50 articles were excluded after full-text analysis.Of these, seven had been conducted in Asia, two in Europe, one compared the European and Asian realities, and the remaining ones had been carried out in North America.
In these studies, a mean age of 39.5 years and 66.7% to 100% of female participants were found, which is slightly different from the Portuguese reality.In most studies (94%), Nurses had moderate levels of Job Empowerment, whereas in 6% of them they showed high levels, thus revealing the positive relationship between empowerment and job satisfaction.In 14 of the analysed studies, the direct and positive relationship between empowerment and job satisfaction is clearly shown.Thus, the higher the professionals' level of empowerment, the higher their level of satisfaction.Although this relationship is not clearly revealed in other studies, its presence may be inferred.The more empowered Nurses feel, the more professionally satisfied they will be: fair/high levels of job empowerment correspond to fair/high levels of job satisfaction.
A clear relationship was found between the perception of empowerment and age (higher levels of empowerment in older nurses), academic qualifications and professional certification (the level of empowerment increases with academic qualifications and professional certification), professional context (higher levels of empowerment among Advanced Practice Nurses), and geographical context (in different realities, the determinants of empowerment may be different: in North America, the dimension opportunity scored higher than in studies carried out in Asia).

Table 2
Number of results according to the database and the respective refinement by subject

Table 4
Descriptive statistics of demographic data