Structural empowerment of nurses in emergency services: an integrative review

Abstract

Objective

to synthesize and analyze the scientific evidence on the structural empowerment of nurses, specifically in the context of the emergency room.

Methods

An integrative literature review was carried out using the electronic databases Lilacs, PubMed, Scopus, Web of Science and Embase. 174 articles were identified in the databases, considering the inclusion and exclusion criteria: original studies, in Portuguese, English and Spanish, published from 1996 onwards and whose scope was work on the structural empowerment of nurses working in the various emergency scenarios. After evaluating and refining the studies using the established criteria, a total of six studies were obtained for analysis.

Results

Two thematic categories were established to synthesize the knowledge: “the dimensions of structural empowerment of emergency nurses” and “the relationship between nurses’ structural empowerment and other variables and their impact in the emergency context”. These thematic categories made it clear that opportunity is fundamental to nurses’ empowerment in this context, as well as the relevance of leadership and the work environment as important components that influence nurses’ empowerment and professional practice.

Conclusion

Structural empowerment is significant for nurses’ professional practice in the context of emergencies, since having access to the dimensions of empowerment results in autonomy at work, higher levels of self-efficacy and an improvement in the quality and safety of the care provided.

Empowerment; Nurses; Emergencies; Emergency medical services

Resumo

Objetivo

Sintetizar e analisar as evidências científicas acerca do empoderamento estrutural dos enfermeiros, especificamente no contexto da emergência.

Métodos

Revisão integrativa da literatura realizada nas bases de dados eletrônicas: Lilacs, PubMed, Scopus, Web of Science e Embase. Foram identificados 174 artigos nas bases de dados, considerando-se os critérios de inclusão e exclusão: estudos originais, nos idiomas português, inglês e espanhol, publicados a partir de 1996 e cujo escopo fossem os trabalhos acerca do empoderamento estrutural de enfermeiros atuantes nos diversos cenários da emergência. Após a avaliação e os refinamentos dos trabalhos por intermédio dos critérios estabelecidos, obteve-se um total de seis estudos para análise.

Resultados

Foram estabelecidas duas categorias temáticas para sintetizar o conhecimento: “as dimensões do empoderamento estrutural dos enfermeiros da emergência” e “a relação do empoderamento estrutural dos enfermeiros com outras variáveis e seu impacto no contexto da emergência”. Essas categorias temáticas permitiram evidenciar que a oportunidade é fundamental para o empoderamento do enfermeiro nesse contexto, além disso, observou-se a relevância da liderança e o ambiente de trabalho como componentes importantes que influenciam no empoderamento e na prática profissional do enfermeiro.

Conclusão

O empoderamento estrutural é significativo para prática profissional do enfermeiro no contexto da emergência, pois ter acesso às dimensões de empoderamento resulta em autonomia no trabalho, níveis maiores de autoeficácia e melhoria na qualidade e segurança da assistência prestada.

Empoderamento; Enfermeiras e Enfermeiros; Emergências; Serviços médicos de emergência

Resumen

Objetivo

Sintetizar y analizar las evidencias científicas sobre el empoderamiento estructural de los enfermeros, específicamente en el contexto de emergencias.

Métodos

Revisión integradora de la literatura realizada en las bases de datos electrónicas Lilacs, PubMed, Scopus, Web of Science y Embase. Se identificaron 174 artículos en las bases de datos, con los siguientes criterios de inclusión y exclusión: estudios originales, en portugués, inglés y español, publicados a partir de 1996, cuyo alcance eran los trabajos sobre el empoderamiento estructural de enfermeros que trabajan en diferentes escenarios de emergencias. Después de la evaluación y la refinación de los trabajos mediante los criterios establecidos, se obtuvo un total de seis estudios para el análisis.

Resultados

Se establecieron dos categorías temáticas para sintetizar el conocimiento: “las dimensiones del empoderamiento estructural de los enfermeros de emergencias” y “la relación del empoderamiento estructural de los enfermeros con otras variables y el impacto en el contexto de emergencias”. Estas categorías temáticas permitieron evidenciar que la oportunidad es fundamental para el empoderamiento de los enfermeros en este contexto. Además, se observó la relevancia del liderazgo y del ambiente de trabajo como componentes importantes que influyen en el empoderamiento y en la práctica profesional de los enfermeros.

Conclusión

El empoderamiento estructural es significativo para la práctica profesional de los enfermeros en el contexto de emergencias, ya que tener acceso a las dimensiones del empoderamiento tiene como resultado la autonomía en el trabajo, mayores niveles de autoeficacia y una mejora de la calidad y seguridad de la atención brindada.

Empoderamiento; Enfermeras y Enfermeros; Urgencias médicas; Servicios médicos de urgencia

Introduction

In the context of nursing, empowerment is used as a comprehensive concept to describe elements of professional growth and development. Thus, in order for nurses to perform their duties properly, it is important for health organizations to adopt management models and policies that enhance the empowerment of these professionals.(¹)

Empowerment is an emerging product of interactions between individual, organizational and socio-cultural factors.(²) A Finnish study points out that healthcare organizations should provide resources and conditions to develop the autonomy of their nurses, so that they feel more empowered, even in a challenging and stressful environment.(³)

Access to information, support, resources, leadership and opportunities facilitate the experience of intrinsic motivation for successful management practices and autonomy.(⁴)Therefore, it is valid to point out that empowered nurses should be seen as those who have the ability to choose and carry out permitted actions, direct their own growth in the desired way, open up possibilities for growth and practice, enhance individual and collective participation in the profession, as well as increasing the power of nursing.(⁵)

The empowerment of nurses and their subsequent sense of personal control over their own work environment is essential for several reasons. Firstly, a lack of empowerment in nursing can lead to inadequate management of wards, generate costs, as well as an increase in nurses who are less satisfied with their jobs and consequently more susceptible to burnout.(⁴,⁶) In addition, less empowered nurses become more frustrated when trying to improve their professional practice and innovate in patient care.(⁵)

Empowerment is considered one of the main management practices and plays a fundamental role in nurses’ professional practice environments.(⁵-⁷)Considering this organizational context, there are various theoretical conceptions on the subject of empowerment, such as the theory of psychological empowerment, the theory of group empowerment and structural empowerment.(⁶) For this review, the latter perspective of empowerment was used, as it considers empowerment as a social and political force that can influence organizational conditions and practices. (¹,⁶)

Structural empowerment is understood to be about an organization’s ability to provide employees with access to the resources they need to support their work. It refers to the specific social conditions and policies of the workplace that facilitate access to opportunities, information, support and resources, taking into account the characteristics of formal or informal powers.(⁸)

Nurses’ perceptions of empowerment in the workplace affect their performance and motivation. In this way, nurses’ structural empowerment can lead to increased motivation, a sense of confidence, autonomy, and positive work-related attitudes, such as: job satisfaction, organizational commitment, intention to stay, low attrition and increased confidence. In addition, it has a positive effect on the provision of high-quality patient care, work effectiveness and the patient safety climate.(⁷,⁸)

Considering the relevance of structural empowerment for nursing, it is essential to carry out research on the subject in the various settings in which nurses work. Nurses’ perceptions of levels of empowerment in the organization have been linked to higher levels of motivation, commitment and engagement at work.(⁹) Such results are desirable among nurses working in intensive care areas with high health demands, such as urgent and emergency care units.

The role of nurses in urgent and emergency services is of great importance, given that they are directly in contact with the patient, from the first moment at the scene, via the pre-hospital service, to the moment of discharge or transfer to another unit or institution.(¹⁰) Emergency nurses work autonomously in a chaotic and stressful environment, so they rely on the knowledge they have acquired throughout their academic and professional careers to feel safe, confident and empowered in their professional practice.(¹¹)

In this sense, it is worth pointing out that urgent and emergency care environments deserve investment in research that addresses the empowerment of nurses, since the most recent reviews on this competence predominantly point to conceptual aspects or theoretical conceptions, without taking into account the specificity of this context,(⁵,⁶) characterized by the fact that they are intended for a considerable portion of the population, because they are places with a large flow of care, in addition to the high complexity of the assistance provided.(¹²)

Corroborating this finding, the authors reaffirm that, although the literature includes studies on nurse empowerment in many other clinical areas, there is a need for studies on empowerment among nurses in the urgent and emergency care context.(¹¹) In view of the above, this article aims to synthesize and analyze the scientific evidence related to the structural empowerment of nurses, specifically in the context of urgent and emergency care.

Methods

This research is an integrative literature review considering the six stages established by a group of researchers in 2008.(¹³) In addition, the recommendations of the PRISMA 2020 (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist were followed to construct the flowchart and this article. It is worth noting that although it is characterized as a tool for systematic reviews, it has also been used to guide the writing of integrative reviews.(¹⁴) In addition, this integrative review has been registered with the Open Science Framework (OSF), with access via the electronic address: https://osf.io/xybv4/, under the identification number: DOI-10.17605/OSF.IO/XYBV4.

The integrative review was chosen because this method enables the synthesis of multiple published studies and general conclusions about a particular focus of study, using the methodology, theory or results of a variety of studies in which the research designs are diverse. To this end, this research carefully considered:(¹³)

1. Selection of the guiding question: The PCC strategy was adopted for this stage. In this acronym, the letters correspond to: P - Population, C Concept and C - Context. In the same vein, it should be reiterated that the choice of descriptors can take into account ideas implicit in the question to be answered.(¹⁵) Thus, transposing the acronym to the present study, the letter P refers to Nurses, C to Structural Empowerment and C covers the context of urgency and emergency, which resulted in the research question: “What scientific evidence has been produced about the structural empowerment of nurses in the context of urgency and emergency units?”.

2. Determination of inclusion and exclusion criteria and literature search: Original studies in Portuguese, English and Spanish, published from 1996 onwards, the year in which the first studies on structural empowerment in nursing were published, were included.(¹⁶) In addition to studies covering all urgent and emergency contexts (pre-hospital, emergency hospitals, emergency rooms and urgent/emergency departments). The following were excluded from the search: theses, dissertations, articles that dealt with professionals other than nurses, opinion articles and editorials, as well as reviews of any kind, since priority was given to original articles. The databases were searched from August to November 2022.

3. Categorization of studies: the information to be extracted (year of publication; country; study design; number of participants; study objective(s); outcomes and main findings and; conclusions) was defined, taking into account the elements proposed by PRISMA, with a view to organizing and establishing the database;(¹⁴)

4. Evaluation of the studies included in the integrative review: a preliminary reading of the titles and abstracts of the selected articles was carried out, followed by a more in-depth analysis of the remainder, resulting in the selection of the studies that answered the research question, thus obtaining the sample of studies that made up the review. The articles were stratified according to levels of evidence: level I - evidence from a systematic review, meta-analysis or articles from guidelines of all Randomized Controlled Clinical Trials (RCTs); II - evidence obtained from one or more RCTs, with a good design; III - evidence from controlled studies without randomization; IV - evidence from well-designed case-control or cohort studies; V - evidence from a systematic review of qualitative and descriptive studies; VI - evidence from a single descriptive or qualitative study; and level VII, which includes evidence from expert opinion and/or reports from expert committees;(¹⁷)

5. Interpretation of results: based on the articles selected, thematic categories were established to synthesize the results that converged;

6. Presentation of the review with a synthesis of the knowledge produced.

To obtain the articles, the following electronic databases were consulted: Latin American and Caribbean Health Sciences Literature (Lilacs) and the National Library of Medicine (Medline) through the PubMed portal, Scopus, Web of Science and Embase. The controlled descriptors used were: DeCS (Health Science Descriptors) “nursing”, “emergency”, in MeSH (Medical Subject Headings) and EMTREE “nursing” and “emergency”, as well as the keyword “structural empowerment” and its respective English inflection “structural empowerment”. The Boolean logical operators “AND” and “OR” were used to cross-reference the terms to obtain the greatest number of possible articles to answer the guiding question. Chart 1 shows the search strategies in the respective databases.

Chart 1
Database search strategies

Database strategies	Quantitative search results (n)
PubMed
nursing AND emergency AND structural empowerment	133
Lilacs
enfermagem AND empoderamento estrutural AND emergência AND (db:("Lilacs"))	3
Web of Science
nursing AND structural empowerment AND emergency	18
SCOPUS
(nursing AND structural AND empowerment AND emergency)	9
EMBASE
(‘nursing'/exp OR nursing) AND ('emergency'/exp OR emergency) AND ('structural empowerment' OR (structural) AND ('empowerment'/exp OR empowerment)	11
Total articles	174

The articles were reviewed by groups of two researchers, always consisting of a student-researcher and a teacher-researcher. When there was a disagreement between the researchers on one of the papers, a third member (researcher-professor) was consulted. To organize and manage this stage, Rayyan® software was used to systematically select articles, remove duplicate articles and blind the researchers’ evaluation. It is worth noting that ethical aspects and copyright were safeguarded, and the authors of the papers are duly referenced, in order to comply with national resolutions on research ethics. As a result of the bibliographical nature of the research, approval of the project by the Research Ethics Committee was waived.

Results

A total of 174 articles were identified, nine in Scopus, 18 in Web of Science, 133 in Medline/PubMed, 11 in Embase and three in Lilacs. Six articles met the inclusion criteria, as shown in figure 1, drawn up in accordance with the PRISMA recommendations.(¹⁴)

Figure 1
Flowchart for selecting articles in PRISMA

The characterization of the articles is summarized in Chart 2, which contains: the year of publication, the country where the article was published, the research design, the level of evidence, the number of participants, the objective of the study, the outcome/main findings about the empowerment of nurses in emergency wards and the conclusion(s).

Chart 2
Summary table of the studies selected from the integrative review

Author(s)	Year of publication/ Country	Study design/level of evidence	n of participants/ aim of study	Outcomes/main findings on the empowerment of nurses in emergency units and conclusions
Krebs, Madigan, Tullai-McGuinness(18)	2008/ EUA	Analytical observational study/ Level VI	Ninety-seven (63%) nurses filled in the questionnaires. Of these professionals, 33 (34%) corresponded to the emergency sector. Objective: to examine the working environment of nurses in rural areas in all settings, describing the relationship between structural empowerment and the characteristics of the nurse's working environment.	The mean score for the measuring instrument was 18.60, with a standard deviation of 2.86 among the professionals working in the emergency department. There was no statistically significant difference between emergency nurses and the other two sectors analyzed in the study - home care and medical/surgical unit nurses. There was a positive correlation between the working environment of emergency nurses and their level of structural empowerment. In relation to the domains of these same professionals, the following values were obtained (mean; standard deviation): Opportunity (3.94; 0.80); Information (2.86; 0.94); Support (2.66; 0.66); Resources (2.88; 0.64); Formal power (2.85; 0.58); Informal power (3.41; 0.71); and Overall empowerment (3.18; 0.76). Conclusion: The findings of this study showed a positive correlation between the working environment of nurses in rural areas (in various sectors, including the emergency room) and their level of structural empowerment.
Young-Ritchie, Spence Laschinger, Wong(4)	2009/ Canada	Non-experimental predictive research to test the hypothetical model/ Level VI	Random sample of 300 nurses from emergency departments (EDs) in acute care hospitals. Objective: To test a model about nurses' perceptions of their line leaders' emotionally intelligent leadership behavior in relation to structural empowerment and organizational commitment.	Emergency team nurses perceived their work environment as only moderately empowering (M=18.36, SD=3.22). With regard to the dimensions of empowerment, the nurses in this sample perceived (mean; standard deviation): Opportunity (4.26; 0.70); Informal power (3.48; 0.77); Information (2.76; 0.85); and Support (2.72; 0.91). The least empowering dimensions were Access to Formal Power (2.50; 0.82) and Resources (2.67; 0.73). Emotionally intelligent leadership behavior had a strong effect on structural empowerment (β=0.54) which, in turn, had a direct effect on affective commitment (β=0.61). Access to Support and Formal Power were more strongly related to general managerial emotional intelligence (r=0.53 and p=0.40, respectively), and access to Opportunities less strongly (r=0.16, p<0.05). Conclusions: Nurses' perceptions of empowerment were strongly influenced by emotionally intelligent leadership behaviour and consequently had an impact on their organizational commitment.
Fitzpatrick, Campo, Gacki-Smith(11)	2014/ USA	Descriptive study/ Level VI	The total sample consisted of 2,633 participants. Objective: To determine the differences between certified and non-certified emergency nurses in the perception of structural empowerment, turnover, intention to leave the current position and intention to leave the nursing profession.	There was a statistical difference between nurses who had emergency certification and those who did not, with regard to formal power (t=-3.24, p=0.001). However, there were no statistically significant differences in the other subscales (Opportunity, Information, Support, Resources and Informal power) and total empowerment scores. Participants who reported working full-time had higher levels of empowerment than those who worked part-time in the Opportunity (t = 2.01, p=0.04), Information (t=4.58, p<0.001), Support (t=1.96, p=0.05), Formal Power (t=3.87, p<0.001) and Total Empowerment (t=3.18, p=0.001) subscales. The only significant difference in empowerment scores based on gender was in the Opportunity subscale (t=-2.68, p=0.01); women perceived more opportunities. The role of emergency nurses was assessed and delineated into four categories: team nurses, manager/supervisor/director, advanced practice nurse and other. There were significant differences between the groups in all subscales and total scores of empowerment, except for resource, with team nurses scoring higher in all subscales except the resource subscale. Conclusions: There were statistically significant differences between emergency nurses considering certification, in various dimensions of empowerment.
Connolly, Jacobs, Scott(19)	2018/ New Zealand	Descriptive study mixed method/ Level VI	Out of a total of 112 nurses from an emergency department invited to take part in the study, only a total of 37 professionals completed the questionnaires. Objective: To examine the clinical leadership of nurses in an emergency department and the importance of nurses feeling psychologically and structurally empowered to act as clinical leaders.	There was no statistically significant relationship between clinical leadership and structural empowerment. In relation to the domains of these same professionals, the following values were obtained (mean; standard deviation): Opportunity (3.92; 0.66); Information (2.77; 0.87); Support (2.61; 0.85); Resources (2.41; 0.65); Formal power (2.35; 0.71); Informal power (3.21; 0.53); and Total score of the Structural Empowerment scale (13.36; 2.38). Conclusions: The overall results showed that most emergency nurses felt that they performed clinical leadership behaviors, but that their ability to act as clinical leaders was limited by a lack of structural empowerment.
Alhalal, Alrashidi, Alanazi(20)	2020/ Saudi Arabia	Analytical observational study/ Level VI	Random sample of 255 nurses from five acute care hospitals in Saudi Arabia, 96 (37.6%) of whom are “emergency nurses”. Objective: To assess the predictors of patient-centered care among nurses working in an acute care setting, including structural empowerment.	The mean score for the empowerment instrument was 14.83, with a standard deviation of 3.47 for nurses working in emergency units. Multiple linear regression revealed that structural empowerment (β=0.273 [95%]; CI: [0.462-1.427]) together with compassion satisfaction and burnout explained the significant variation (27.5%) in the provision of patient-centered care by nurses. Conclusions: In a more global aspect of the study, multiple linear regression showed that lower burnout, higher compassion satisfaction and structural empowerment increase the provision of patient-centered care by nurses.
Torquetti, Camponogara, Schneider, Freitas, Moura, Miorin(12)	2021/ Brazil	Mixed-method descriptive study/ Level VI	Nurses who carry out care activities in the adult emergency room (21 nurses in the quantitative study and 14 in the qualitative study). Objective: to assess the structural empowerment of nurses working in emergency rooms.	Considering the dimensions of empowerment, the following were observed (mean; standard deviation): Opportunity (4.54; 0.6); Informal power (3.12; 1.0); Resources (2.82; 0.8); Support (2.58; 1.1); Formal power (2.56; 1.0); and Information (2.54; 1.0). The instrument as a whole had a mean=18.16 and SD=0.9, thus denoting a moderate level of empowerment. From the perspective of the qualitative data, negative points were noted that need to be improved. On the other hand, there were positive points that favored empowerment: the opportunity to take part in projects at the unit; the nurses’ good relationship with the health team; access to support, in terms of guidance offered by management in situations considered more complex; and the ability to make decisions regarding direct user care and issues related to the unit’s routine. Conclusions: quantitative data: nurses had a moderate level of structural empowerment. The "access to opportunity" dimension was the construct with the highest value; qualitative data: the informal power dimension was perceived positively, while the opportunity, information, resources, support and formal power dimensions were perceived as insufficient.

All the articles had level VI evidence, i.e. they were descriptive or qualitative studies. The six articles (16.66%) were published in different years: 2008, 2009, 2014, 2018, 2020 and 2021. Considering the countries in which the research was carried out, there was a concentration of productions on the American continent, with a total of four articles (66.66%), and the country with the highest number of publications was the United States of America (USA), which produced two articles (33.32%). In Brazil, only one article on this subject was identified (16.66%).

Discussion

Based on the findings of the articles and presented in Chart 2, the aspects that converge and contrast between the works were analyzed, thus establishing two thematic categories for discussion of the works: “the dimensions of the structural empowerment of emergency nurses” and “the relationship between the structural empowerment of nurses and other variables and their impact in the context of the emergency room”.

The dimensions of structural empowerment of emergency room nurses

“Opportunity” was the dimension of structural empowerment that showed the highest average compared to the others, with the Brazilian study showing the highest value, followed by cane work.(⁴,¹²) This demonstrates that emergency units are opportune spaces for nurses to learn and develop professionally, enhancing their power in these working spaces.(¹,⁷) A study identified a significant difference in the “opportunity” dimension between the Emergency Room (ER) and the Intensive Care Unit (ICU), showing that ER nurses have more opportunities than ICU nurses.(¹)

Even so, from the qualitative analysis of the mixed study carried out in Brazil, it was possible to note that for some nurses there are still insufficient opportunities for further training in the emergency area.(¹²) In this sense, the role of Permanent Health Education for the nursing team stands out, as this strategy considers the singularity and multidimensionality of its actors, with a view to making them protagonists in the process of (re)signification of continuous and permanent learning.(²⁰,²¹)

In four of the six studies selected, the “Informal power” dimension had the second highest average.(⁴,¹²,¹⁸,¹⁹) Considering these findings, it is worth noting the study carried out in four hospitals in Jordan, which showed that different levels of informal power influence the other dimensions of structural empowerment.(²²)

This domain of structural empowerment is characterized by an employee’s strong relationships inside or outside the organization, unlike formal power which refers to the power deriving from an employee’s position in the organization.(²³) Informal power was also pointed out as a positive point in the qualitative analysis of the study with nurses working in emergency rooms in Brazil, given the good relationship between nurses.(¹²)

Access to information refers to knowledge of organizational changes and policies, as well as the technical knowledge that is fundamental to doing the job.(⁸) In this sense, given the importance of access to information in professional practice, it was observed in this review that one study obtained the lowest average in the empowerment instrument for the “Information” domain and in another study this dimension obtained the third lowest average.(¹²,¹⁸) These results highlight the importance of communication between managers and health professionals, in order to obtain and share information, which requires dialogic spaces and effective/direct communication between these actors in urgent and emergency services.(²⁴)

The relationship between nurses’ structural empowerment and other variables and its impact in the emergency context

The leadership of nurses in the emergency context was one of the variables analyzed for correlation in two of the six studies identified in this integrative review.(⁴,¹⁹)

According to the findings of work carried out in Canada, resonant leadership behavior had a strong effect on structural empowerment (β=0.54) which, in turn, had a direct effect on affective commitment (β=0.61).(⁴) These findings are in line with the results of a systematic review showing that resonant leadership, as well as other leadership styles (transformational, authentic and supportive), have a positive effect on the empowerment of nursing staff. On the other hand, passive and transactional leadership styles were associated with a negative effect on the empowerment process.(²⁵)

Although no statistically significant correlation was found between the clinical leadership and structural empowerment of emergency nurses, the study carried out in New Zealand indicates that the clinical leadership of the emergency department nurses investigated is limited by the lack of structural empowerment present in the organization.(¹⁹)

The relationship between structural empowerment and clinical leadership was also investigated in two other studies - Canadian and Turkish - carried out in hospital units.(²⁶,²⁷) The results of the work carried out in Ontario, Canada, indicate that the structural empowerment and clinical leadership of nurses are essential to strengthen patient safety, and that this must be based on transformational leadership.(²⁶) On the other hand, research carried out in hospitals in Turkey shows that improved nurse practitioner performance requires strong but clinical leadership within a creative team climate where structural empowerment prevails.(²⁷)

The US study showed a positive correlation between the nurse’s working environment and the level of structural empowerment.(¹⁸) In this sense, it is important to emphasize that emergency units have to encourage nurse empowerment in order to enable greater job satisfaction, engagement and organizational commitment, as well as having a positive impact on the performance of their duties and their productivity.(⁹,¹¹,¹²)

Multiple linear regression performed in the Saudi Arabian study on critical care units, including the emergency unit, revealed that structural empowerment together with compassion satisfaction and burnout explained significant variation (27.5%) in the provision of patient-centered care by nurses.(²⁰)

In line with this study, a meta-analysis revealed that structural empowerment has an inverse correlation with nurses’ emotional exhaustion (burnout), i.e. as nurses feel more empowered, they experience less emotional exhaustion.(²⁸)Consequently, the correlation between these two variables - structural empowerment and emotional exhaustion - influences both quality of life at work and patient care.(⁷, ²⁹,³⁰)

The study carried out in the USA in 2014 revealed a statistical difference between nurses who had emergency certification and those who did not, with regard to the Personal Power dimension (t=-3.24, p=0.001). In addition, in the same study, participants who worked full-time had higher levels of empowerment than those who worked part-time in the Opportunity (t=2.01, p=0.04), Information (t=4.58, p<0.001), Support (t=1.96, p=0.05), Formal Power (t=3.87, p<0.001) and Total Empowerment (t=3.18, p=0.001) subscales.(¹¹)

Thus, it is understood that nurses working in these organizations must be able to respond to challenges with skill and professional knowledge. Unless nurses feel empowered to act, they will rely on rigid bureaucratic structures (formal power) rather than their own power to guide their practice. For this reason, organizations should not limit nurses’ autonomy and thus restrict their ability to achieve extraordinary results.(²)

Although the term “structural empowerment” has a well-established theoretical framework, it is not yet considered as a descriptor in national and international databases, which can be seen as a limiting factor in searches. Another limiting factor may have been the language, as research carried out in languages other than those used in this review may not have been found.

Thus, based on the results of this study and taking into account the total of six manuscripts, it is important to develop new studies on the subject and on this very specific professional nursing practice environment. It is suggested that new research should also use varied methodological approaches and correlate other variables, as observed in some of the articles selected in this review.

Conclusion

Structural empowerment is essential for nurses’ professional practice in the context of emergencies. The dimensions of structural empowerment - Opportunity, Informal Power - were the most evident in the articles included in the review, thus contributing to autonomy at work and better levels of self-efficacy, especially when aligned with the development of resonant and clinical leadership in these professionals. Finally, the six studies identified converge on the importance of empowering emergency nurses in their work environment, enabling them to make more assertive decisions that directly and indirectly impact on patient safety and quality of care.

Referências

• ¹
  Moura LN, Camponogara S, Santos JL, Gasparino RC, Silva RM, Freitas ED. Structural empowerment of nurses in the hospital setting. Rev Lat Am Enfermagem. 2020 Nov 6;28:e3373.
• ²
  Cardoso Teixeira A, Nogueira A, Nunes JR, Teixeira L, Céu Barbieri-Figueiredo M. Professional empowerment among Portuguese nursing staff: a correlational study. J Nurs Manag. 2021;29(5):1120-9.
• ³
  Niinihuhta M, Terkamo-Moisio A, Kvist T, Häggman-Laitila A. Nurse leaders' work-related well-being-Relationships to a superior's transformational leadership style and structural empowerment. J Nurs Manag. 2022;30(7):2791-800.
• ⁴
  Young-Ritchie C, Spence Laschinger HK, Wong C. The effects of emotionally intelligent leadership behaviour on emergency staff nurses' workplace empowerment and organizational commitment. Nurs Leadersh (Tor Ont). 2009;22(1):70-85.
• ⁵
  Woodward KF. Individual nurse empowerment: a concept analysis. Nurs Forum. 2020;55(2):136-43.
• ⁶
  Friend ML, Sieloff CL. Empowerment in nursing literature: an update and look to the future. Nurs Sci Q. 2018;31(4):355-61.
• ⁷
  Newberry LW. Using Structural Empowerment to Improve Outcomes. J Nurs Adm. 2021;51(7-8):359-61.
• ⁸
  Fragkos KC, Makrykosta P, Frangos CC. Structural empowerment is a strong predictor of organizational commitment in nurses: a systematic review and meta-analysis. J Adv Nurs. 2020;76(4):939-62.
• ⁹
  García-Sierra R, Fernández-Castro J. Relationships between leadership, structural empowerment, and engagement in nurses. J Adv Nurs. 2018;74(12):2809-19.
• ¹⁰
  Donelan K, DesRoches CM, Guzikowski S, Dittus RS, Buerhaus P. Physician and nurse practitioner roles in emergency, trauma, critical, and intensive care. Nurs Outlook. 2020;68(5):591-600.
• ¹¹
  Fitzpatrick JJ, Campo TM, Gacki-Smith J. Emergency care nurses: certification, empowerment, and work-related variables. J Emerg Nurs. 2014;40(2):e37-43.
• ¹²
  Torquetti AB, Camponogara S, Schneider FV, Freitas EO, Moura LN, Miorin JD. Structural empowerment of nurses working in an emergency room: a mixed methods study. Rev Enferm UERJ. 2021;29:e62928.
• ¹³
  Mendes KD, Silveira RC, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Context Enferm. 2008;17(4):758-64. Review.
• ¹⁴
  Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372(71):n71.
• ¹⁵
  The Joanna Briggs Institute (JBI). Joanna Briggs Institute Reviewers' Manual: 2015 edition/supplement. Adelaide: JBI; 2015 [cited 2023 Jan 25]. Available from: https://nursing.lsuhsc.edu/JBI/docs/ReviewersManuals/Scoping-.pdf
  » https://nursing.lsuhsc.edu/JBI/docs/ReviewersManuals/Scoping-.pdf
• ¹⁶
  Spence Laschinger HK. A theoretical approach to studying work empowerment in nursing: a review of studies testing Kanter's theory of structural power in organizations. Nurs Adm Q. 1996;20(2):25-41. Review.
• ¹⁷
  Melnyk BM, Fineout-Overholt E. Evidence-based practice in nursing & healthcare: a guide to best practice. 3rd ed. Philadelphia: Wolters Kluwer Health/Lippincott; 2014. 625 pp.
• ¹⁸
  Krebs JP, Madigan EA, Tullai-McGuinness S. The rural nurse work environment and structural empowerment. Policy Polit Nurs Pract. 2008;9(1):28-39.
• ¹⁹
  Connolly M, Jacobs S, Scott K. Clinical leadership, structural empowerment and psychological empowerment of registered nurses working in an emergency department. J Nurs Manag. 2018;26(7):881-7.
• ²⁰
  Alhalal E, Alrashidi LM, Alanazi AN. Predictors of patient-centered care provision among nurses in acute care setting. J Nurs Manag. 2020;28(6):1400-9.
• ²¹
  Backes DS, Bär K, Costenaro RG, Backes MT, Souza FG, Büscher A. Educação permanente: percepção da enfermagem à luz do pensamento da complexidade. Acta Paul Enferm. 2022;35:eAPE01906.
• ²²
  Al-Hammouri MM, Rababah JA, Ta'an WF. Structural empowerment, formal and informal power, and job performance quality: a moderated mediation analysis. J Nurs Manag. 2021;29(6):1596-602.
• ²³
  Arslan Yürümezoglu H, Kocaman G. Structural empowerment, workplace incivility, nurses' intentions to leave their organisation and profession: a path analysis. J Nurs Manag. 2019;27(4):732-9.
• ²⁴
  Cunha SG, Siman AG, Brito MJ. A comunicação como recurso para tomada de decisão de gestores da unidade de atendimento imediato. Brazilian J Heal Rev. 2020;3(2):2374-83.
• ²⁵
  Cummings GG, Tate K, Lee S, Wong CA, Paananen T, Micaroni SP, et al. Leadership styles and outcome patterns for the nursing workforce and work environment: a systematic review. Int J Nurs Stud. 2018;85:19-60. Review.
• ²⁶
  Boamah S. Linking Nurses' Clinical Leadership to Patient Care Quality: The Role of Transformational Leadership and Workplace Empowerment. Can J Nurs Res. 2018;50(1):9-19.
• ²⁷
  Kuscu Karatepe H, Türkmen E. Nurse performance: A path model of clinical leadership, creative team climate and structural empowerment. J Clin Nurs. 2023;32(3-4):584-96.
• ²⁸
  Zhang X, Ye H, Li Y. Correlates of structural empowerment, psychological empowerment and emotional exhaustion among registered nurses: a meta-analysis. Appl Nurs Res. 2018;42:9-16.
• ²⁹
  Nursalam N, Fibriansari RD, Yuwono SR, Hadi M, Efendi F, Bushy A. Development of an empowerment model for burnout syndrome and quality of nursing work life in Indonesia. Int J Nurs Sci. 2018;5(4):390-5.
• ³⁰
  Ispir Demir Ö, Yildirim A, Sönmez B, Duygulu S. Relationship between structural empowerment and nurse and patient-reported outcomes: the mediating role of control over nursing practices. West J Nurs Res. 2023;45(7):634-45.

Edited by

Associate Editor (Peer review process): Alexandre Pazetto Balsanelli (https://orcid.org/0000-0003-3757-1061) Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil

Publication Dates

• Publication in this collection
  08 July 2024
• Date of issue
  2024

History

• Received
  17 July 2023
• Accepted
  15 Feb 2024