Psychological empowerment of health professionals

Empoderamiento psicológico de profesionales de la salud

ABSTRACT

Objective:

To assess whether there are differences in psychological empowerment between different health professionals working in a teaching hospital.

Method:

A comparative, quantitative, and cross-sectional study carried out with 165 professionals selected at random and who worked in a teaching hospital in the inland of the state of São Paulo. The participants were divided into three groups: 1) nurses, 2) physicians, and 3) other professionals (physiotherapists, psychologists, pharmacists, speech therapists, social workers, and nutritionists). For data collection, a form was used to characterize the sample, as well as the Brazilian version of the Psychological Empowerment Instrument. To compare the scores between the three groups, the Kruskal-Wallis test was used, followed by Dunn' post-test.

Results:

Nurses, physicians, and other professionals scored 71.4; 69.3, and 71.1 points (p=0.5959), respectively, in the total score of the instrument

Conclusion:

There are no statistically significant differences in the perception of psychological empowerment of different health professionals.

Conclusion:

There are no statistically significant differences in the perception of psychological empowerment of different health professionals.

Keywords:
Power, psychological; Health personnel; Clinical competence; Nursing

RESUMEN

Objetivo:

Evaluar si existen diferencias en el empoderamiento psicológico entre diferentes profesionales de la salud que trabajan en un hospital universitario.

Método:

Estudio comparativo, cuantitativo y transversal, realizado con 165 profesionales seleccionados al azar y que trabajaban en un hospital universitario en el interior de São Paulo. Los participantes se dividieron en tres grupos: 1) enfermeras, 2) médicos y 3) otros profesionales (fisioterapeutas, psicólogos, farmacéuticos, logopedas, trabajadores sociales y nutricionistas). Para la recolección de datos, se utilizó un formulario para caracterizar la muestra y la versión brasileña del Instrumento de Empoderamiento Psicológico. Para comparar las puntuaciones entre los tres grupos, se utilizó la prueba de Kruskal-Wallis, seguida de la prueba post-test de Dunn.

Resultados:

Enfermeras, médicos y otros profesionales obtuvieron promedios de 71,4, 69,3 y 71,1 puntos (p=0,5959), respectivamente, en la puntuación total del instrumento.

Conclusión:

No existen diferencias estadísticamente significativas en la percepción del empoderamiento psicológico de los diferentes profesionales de la salud.

Palabras clave:
Poder, psicológico; Personal de salud; Competencia clínica; Enfermería

RESUMO

Objetivo:

Avaliar se existem diferenças no empoderamento psicológico entre os diferentes profissionais da saúde que atuam em um hospital de ensino.

Método:

Estudo comparativo, quantitativo e transversal, realizado com 165 profissionais selecionados de maneira aleatória e que atuavam em um hospital de ensino do interior de São Paulo. Os participantes foram distribuídos em três grupos: 1) enfermeiros, 2) médicos e 3) outros profissionais (fisioterapeutas, psicólogos, farmacêuticos, fonoaudiólogos, assistentes sociais e nutricionistas). Para a coleta de dados foi utilizada uma ficha para caracterizar a amostra e a versão brasileira do Psychological Empowerment Instrument. Para comparação dos escores entre os três grupos foi utilizado o teste de Kruskal-Wallis, seguido pelo pós-teste de Dunn.

Resultados:

Os enfermeiros, médicos e outros profissionais obtiveram, respectivamente, médias de 71,4; 69,3 e 71,1 pontos (p=0,5959) no escore total do instrumento.

Conclusão:

Não existem diferenças estatisticamente significantes na percepção do empoderamento psicológico dos diferentes profissionais da saúde.

Palavras-chave:
Poder psicológico; Pessoal de saúde; Competência clínica; Enfermagem

INTRODUCTION

The word empowerment has different meanings in different areas of knowledge, being related to the meaning of control and security over certain attitudes. The concept of empowerment originated in the twentieth century, in developed countries, from the struggles for civil rights and the feminist movement. In the 1970s, it was influenced by self-help movements1.

From the 1980s on, empowerment was greatly influenced by community psychology and the management area, being used until today as a tool to delegate authority and responsibility in decision-making, consolidating the role of people and teams, decentralizing power, providing more autonomy, increasing employee engagement, and strengthening relationships of trust among the professionals1^-2.

However, it is important to differentiate between structural and psychological empowerment, as the first is related to the support of resources, information, and conditions that provide learning and professional growth; psychological empowerment, on the other hand, involves the professionals' involvement with their practice environment, that is, how much they are committed and/or motivated to work1.

With regard to nursing, this commitment and motivation can be compromised due to the history of the profession. Until today, nurses face gaps in continuing education, devaluation, lack of recognition, low pay, inequality, and inadequate work opportunities, evidenced by the insufficient number of professionals3. However, the nursing team plays a fundamental role in health care, as it is present even when other professionals are not4.

A number of studies show that empowered professionals are more satisfied and have more autonomy and confidence to make decisions5^-6, factors that can contribute to improving the quality of care and, therefore, if the team who makes up more than half of the health workforce3 feels little or less empowered than the other professionals they work with, organizational results can be seriously compromised.

Considering that nursing is historically undervalued and little recognized, the question that guided this study was the following: Do nurses feel less empowered in the role they play when compared to other health professionals? Given the above, this study aims to assess whether there are differences in psychological empowerment between different health professionals working in a teaching hospital.

METHODS

This is a comparative, quantitative, and cross-sectional study conducted in all the sectors of a teaching hospital in the inland of the state of São Paulo, which has specialized tertiary level services, financed by the United Health System.

The sample consisted of health professionals with higher education who agreed to participate in the research and met the following inclusion criteria: being a nurse, physician, physiotherapist, psychologist, pharmacist, speech therapist, social worker, or nutritionist. Teachers and medical students were excluded from the sample.

Considering that the population of nurses (267) and physicians (338) was considerably higher than that of other professionals [physiotherapists (53), psychologists (2), pharmacists (20), speech therapists (6), social workers (24), and nutritionists (12)], it was decided to divide the sample into three groups: 1) nurses, 2) physicians, and 3) other specialists, and hence the sample size was calculated considering the objective of comparing the three groups.

The methodology of a sample calculation for an ANOVA model was used for the calculation. In this calculation, a significance level of 5%, a test power of 80%, and an effect size equal to 0.25 were established. The calculation resulted in a minimum sample of 159 individuals, 53 per group. From that moment on, a simple random sampling was adopted, stratified by group.

For data collection, a form was used to characterize the sample, as well as the Brazilian version of the Psychological Empowerment Instrument (PEI)1. The characterization form addressed personal (age, gender, marital status) and professional (training, length of experience in the job and in the institution, position, unit of work, work shift, and existence of another employment contract) questions.

The PEI aims to obtain a multidimensional measure of psychological empowerment in the workplace through 12 items divided into four domains: meaning, competence, self-determination, and impact.

The meaning domain (items 2, 5, and 10) concerns the objective of the work, as well as the balance between the requirements of the job and the professionals' beliefs, values, and conducts. Competence (items 1, 9, and 12) is related to the individuals' confidence in carrying out their activities effectively and meeting the expectations of the institution. The self-determination domain (items 3, 7, and 8) represents the professionals' autonomy in the work process. The impact domain (items 4, 6, and 11) shows the level to which the professionals can influence the results in the work environment5.

These items are assessed by a seven-point Likert scale ranging from one (strongly disagree) to seven (strongly agree); where the higher the score, the greater the psychological empowerment. Four is considered a neutral score and the mean of the sum of the participants' answers is used to calculate the score. The score for each domain can vary between three and 21 points, and the total score ranges between 12 and 84 points1.

Data collection was carried out in February and March 2019. The employees were approached individually in their workplaces. Those who met the inclusion criteria were informed about the objectives of the research and received the data collection instruments. The researchers waited for them to be filled out.

The data were tabulated in Microsoft Excel - Windows XP® and analyzed by a statistician using the Statistical Analysis System® (SAS), version 9.4, and the Statistical package for the Social Sciences® (SPSS), version 22.

A descriptive analysis was performed with presentation of absolute and relative frequencies of the qualitative variables and measures of position and dispersion of the quantitative variables (mean and standard deviation). To compare the scores between the three sample groups, the p-value was obtained using the Kruskal-Wallis test, followed by Dunn's post-test. The correlations between the quantitative variables were assessed using Spearman's correlation coefficient. A significance level of p ≤ 0.05 was considered for analysis.

To carry out the study, the researchers requested that all the participants sign the Free and Informed Consent Form, and the regulatory guidelines and standards for research with human beings described in Resolution 466/12 of the National Health Council were observed. The project was approved by the Research Ethics Committee under Opinion No. 3,032,851 on November 22^nd, 2018.

RESULTS

A total of 165 health professionals participated in the study; they had a mean age of 43.1±10.5 years old, length of experience in the job of 14.9±10.5 years, and length of experience in the institution of 13.9±10.3 years. The majority were female (112; 67.9%) and married (108; 65.5%), and 107 (64.8%) had only one employment contract. Among the participants, 71 (43.0%) had a lato sensu Graduate Degree and 73 (38.2%) worked in critical sectors of the hospital (Intensive Care Units, Operating Room, and Emergency Room). The other characteristics of the sample were presented in Table 1.

Table 1 -
Personal and professional characteristics of the sample. Campinas, SP, Brazil, 2019 (n=165)

Variable	n	%
Marital status
Married	108	65.5
Single	39	23.6
Divorced	11	6.7
Widow/Widower	7	4.2
Function
Nurse	56	33.9
Physician	54	32.7
Others	55	33.3
Sector
Critical	63	38.2
Wards	50	30.3
Outpatient	21	12.7
Others	31	18.8
Training
Graduation	25	15.2
Specialization	50	30.3
Internship	21	12.7
Master's degree	39	23.6
PhD	30	18.2
Work shift
Morning	34	20.6
Afternoon	23	13.9
Night	31	18.8
Others	77	46.7

• Source: Research data, 2019.

The assessment and comparison of psychological empowerment between the different categories of health professionals are shown in Table 2.

Table 2 -
Comparison of psychological empowerment between the different professions. Campinas, SP, Brazil, 2019 (n=165)

Domains	Nurses (n=56)		Physicians (n=54)		Others (n=55)		p- value†
	Mean	SD*	Mean	SD*	Mean	SD*
Meaning	18.9	2.4	19.2	2.4	19.1	2.8	0.6844
Competence	18.8	2.3	19.2	2.6	19.9	2.1	0.0046
Self-determination	17.2	2.9	15.8	3.8	16.7	3.7	0.1776
Impact	16.6	3.3	15.2	3.5	15.4	3.4	0.0606
Empowerment	71.4	8.7	69.3	10.2	71.1	9.0	0.5959

• Source: Research data, 2019.
• *SD: Standard Deviation; †p-value obtained my means of the Kruskal-Wallis test.

To assess the difference between the groups with regard to competence (p=0.0046), Dunn's post-test was applied and it was verified that there is a statistically significant difference only between nurses and other professionals, demonstrating that the ‘other professionals’ consider themselves more competent than the nurses.

When comparing the dimensions of the instrument with the personal and professional characteristics of the sample, a significant difference was found between the domain of competence and the ‘another employment contract’ variable, showing that professionals with a double contract feel more competent when compared to those who have only one (p=0.0479).

The quantitative variables were correlated with the dimensions of psychological empowerment and it was verified that, the older the age (r=0.1908, p=0.0141) and the longer the time working in the institution (r=0.1872, p=0.0161), the greater the empowerment of the professional.

DISCUSSION

The data evidenced that, when comparing psychological empowerment between different health professionals, no statistically significant differences were found.

The results surprised the researchers, as the expectation was to find lower levels of empowerment in the group of nurses and higher levels among the physicians, as they are the group of health professionals that concentrates more power and exercises their practice with autonomy7.

In addition, Nursing is a profession that has a historical culture of subordination, plays a more operational role, and is not involved in decision-making and, therefore, has little visibility and recognition in society8.

A possible explanation for the findings that contradicted our hypothesis can be related to the institution's organizational chart, in which nurses are not subordinate to physicians9. The fact that the study was carried out in a reference institution, considered one of the largest university hospitals in Brazil, which, in addition to providing excellent care, has the mission of producing scientific knowledge and training and qualifying human resources, may also have contributed for the nurses to perceive a more autonomous practice.

In the analysis of the domains, Meaning received the highest score for physicians and nurses. When evaluating research studies on empowerment conducted with nurses in Turkey10, United States of America11, and Canada12, similar results were also found.

In this domain, the items describe the self-perception of the importance of the work performed. With regard to the physicians, a study points to the question of the hegemony of the medical discourse in relation to other health professionals7^,13 and, when addressing Nursing, although it is still considered a devalued profession13, the researchers state that this class is essential because, in addition to the patients, they also take care of the needs of the family members during the hospitalization period14. Therefore, it is possible to infer that nurses must be starting to realize the greatness of their work.

In all the professional categories, the Impact domain received the lowest score. Although the professionals believe that their work is important, that they are competent and self-determined, they believe that they do not exercise as much influence and control over the processes carried out in the unit. It is worth mentioning that this research was carried out in a teaching hospital, in which the teachers, especially physicians, have great influence on the decision-making process and, perhaps because of this, the professionals believe they do not have due recognition from their peers15.

The “other professionals” category reached the highest score in the Competence domain. Despite being outnumbered in the health care team, these professionals have been empowered about the importance of their roles, as the configuration of the employment relationships is evolving over time and the multidisciplinary team has been increasingly recognized in the construction of new health practices7.

The fact that the nurses feel less competent in relation to some members of the multidisciplinary team shows that there may be points of vulnerability both in relation to educational issues in the training of nurses and in relation to inadequate work opportunities3.

In the nurse's work process, in addition to the care role, the management aspect16 stands out, which causes these professionals to be under pressure from other nurses, other health professionals, and even from leaders of the institutions, to mobilize and articulate the necessary resources for the provision of care17.

However, these resources are not always available considering the difficulties of replacement, purchasing materials, and hiring staff imposed on the Brazilian public services17, a fact that contributes even further to the distress of the nurses17^-18, who are unable to meet the requests of the teams, and even of the patients themselves.

In addition, the insufficient number of nurses16^,19 and the articulating role they play in the health team18 influence the pace of execution of the activities, demanding that they become more flexible and versatile16.

All these factors can cause negative impacts on patient safety, quality of care16, and on all the dimensions of the psychological empowerment experienced by the professionals, imposing a great challenge to be overcome.

As a result of the precariousness of the nursing work and of the recognition of the importance of the role of nurses in the composition of the multidisciplinary team, a global movement for the appreciation of the profession was started, with its greatest exponent being the Nursing Now campaign. This initiative aims to improve health outcomes by raising the status of nursing as a profession20 and has set the goals of increasing investments in education and professional development, improving working conditions, involving nurses in the health policies, and increasing the number of nurses in leadership positions3.

In assessing the relationship between the domains of the instrument and the personal and professional characteristics of the sample, it was possible to notice that the professionals with two employment contracts felt more empowered, and this may refer to the accumulated experience that contributes to the individuals having more autonomy and control in their actions and initiatives, making their own choices3. In addition, age and time working in the institution were also related to the feeling of greater empowerment, demonstrating that maturity and familiarity with the work environment can contribute to autonomy and, consequently, to decision-making9^,21.

CONCLUSION

In view of the results presented, it was possible to verify that there are no differences between the professional categories with regard to psychological empowerment.

The main limitation of this research lays in the fact that it was carried out in a single university hospital that does not reflect the entire Brazilian reality. This study contributed to demonstrate that reference hospitals, focusing on the excellence of care and on the qualification of their professionals, promote a more autonomous practice for nurses, which contributes to their empowerment. However, it was possible to notice that the goals of the Nursing Now campaign show its urgency in view of the results found, when the domains are evaluated separately.

For the expansion of the population's access to qualified health professionals and the incorporation of new models of care provided in a holistic way and focused on the patient, investments in training, development, and regulation of the working conditions are fundamental for the education and qualification of nurses for this new reality3.

New research studies that evaluate the empowerment of the health professionals, especially nurses, both in public and private institutions, should be carried out in order to verify whether the high level of training reported by the participants in this study influenced the perception of their psychological empowerment, in addition to contributing to the implementation of strategies that boost the empowerment of these professionals and, consequently, the improvement of institutional results.

Acknowledgment:

To the Student Support Service of the Universidade Estadual de Campinas for the scholarship granted.

REFERENCES

• 1. Schumaher MLN, Alexandre NMC. Translation and cultural adaptation of the Psychological Empowerment Instrument for the Brazilian context. Rev Min Enferm. 2017;21:e-1020. doi: https://doi.org/10.5935/1415-2762.20170030
  » https://doi.org/10.5935/1415-2762.20170030
• 2. 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. doi: https://doi.org/10.1111/jonm.12619
  » https://doi.org/10.1111/jonm.12619
• 3. Cassiani SHB, Lira Neto JCG. Nursing Perspectives and the “Nursing Now” Campaign. Rev Bras Enferm. 2018;71(5):2351-2. doi: https://doi.org/10.1590/0034-7167.2018710501
  » https://doi.org/10.1590/0034-7167.2018710501
• 4. Crisp N, Iro E. Nursing now campaign: raising the status of nurses. Lancet. 2018;391(10124):920-1. doi: https://doi.org/10.1016/S0140-6736(18)30494-X
  » https://doi.org/10.1016/S0140-6736(18)30494-X
• 5. Spreitzer GM. Psychological empowerment in the workplace: construct definition, measurement and validation. Acad Manage J. 1995;38(5):1442-65. doi: https://doi.org/10.5465/256865
  » https://doi.org/10.5465/256865
• 6. Teixeira AC, Nogueira MAA, Alves JP. Psychological empowerment in nursing - Portuguese translation, adaptation and validation of "Psychological Empowerment Instrument". Rev Port Enferm Saúde Mental. 2016;16(n.esp):27-33. doi: https://doi.org/10.19131/rpesm.0154
  » https://doi.org/10.19131/rpesm.0154
• 7. Iriart C, Merhy EE. Inter-capitalistic disputes, biomedicalization and hegemonic medical model. Interface Comun Saúde Educ. 2017;21(63):1005-16. doi: http://doi.org/10.1590/1807-57622016.0808
  » http://doi.org/10.1590/1807-57622016.0808
• 8. Salvador PTCO, Alves KYA, Martins CCF, Santos VEP, Tourinho FSV. Reasons for empowerment in nursing: reflections in light of Alfred Schutz. Rev Min Enferm. 2013;17(4):1020-5. doi: https://doi.org/10.5935/1415-2762.20130073
  » https://doi.org/10.5935/1415-2762.20130073
• 9. Teixeira AC, Figueiredo MCB. Nursing empowerment and job satisfaction: an integrative review according the Structural Theory. Rev. Enf. Ref. 2015;6(6):151-60. doi: https://doi.org/10.12707/RIV14024
  » https://doi.org/10.12707/RIV14024
• 10. Ahmet Y, Sidika K, Mesut T, Cahit K. The effect of nurses’ empowerment perceptions on job safety behaviours: a research study in Turkey. Int J Occup Saf Ergon. 2018;3(n. esp):489-96. doi: https://doi.org/10.1080/10803548.2018.1459079
  » https://doi.org/10.1080/10803548.2018.1459079
• 11. DiNapoli JM, O'Flaherty D, Musil C, Clavelle JT, Fitzpatrick JJ. The relationship of clinical nurses’ perceptions of structural and psychological empowerment and engagement on their unit. J Nurs Adm. 2016;46(2):95-100. doi: https://doi.org/10.1097/NNA.0000000000000302
  » https://doi.org/10.1097/NNA.0000000000000302
• 12. Dahinten VS, Lee SE, MacPhee, M. Disentangling the relationships between staff nurses’ workplace empowerment and job satisfaction. J Nurs Manag. 2016;24(8):1060-70. doi: https://doi.org/10.1111/jonm.12407
  » https://doi.org/10.1111/jonm.12407
• 13. Bittencourt MN, Marques MID, Barroso TMMDA. Contributions of nursing theories in the practice of the mental health promotion. Rev Enferm Ref. 2018;(18):125-32. doi: https://doi.org/10.12707/RIV18015
  » https://doi.org/10.12707/RIV18015
• 14. Halfer D, Brewer B. A Professional nursing acute care practice curriculum. J Nurs Adm. 2019;49(2):604-9. doi: https://doi.org/10.1097/NNA.0000000000000823
  » https://doi.org/10.1097/NNA.0000000000000823
• 15. Santos EI, Alves YR, Silva ACSS, Gomes AMT. Professional autonomy and nursing: representations of health professionals. Rev Gaúcha Enferm. 2017;38(1):e59033. doi: https://doi.org/10.1590/1983-1447.2017.01.59033
  » https://doi.org/10.1590/1983-1447.2017.01.59033
• 16. Santos TA, Santos HS, Sampaio ES, Melo CMM, Souza EA, Pires CGS. Intensity of nursing work in public hospitals. Rev Latino-Am Enfermagem. 2020;28:e3267. doi: https://doi.org/10.1590/1518-8345.3221.3267
  » https://doi.org/10.1590/1518-8345.3221.3267
• 17. Araújo-dos-Santos T, Silva-Santos H, Silva MN, Coelho ACC, Pires CGS, Melo CMM. Job insecurity among nurses, nursing technicians and nursing aides in public hospitals. Rev Esc Enferm USP. 2018;52:e03411. doi: https://doi.org/10.1590/S1980-220X2017050503411
  » https://doi.org/10.1590/S1980-220X2017050503411
• 18. Nascimento TCC, Araújo MRM, Almeida SP. Precarização do emprego em um hospital público de Sergipe: um estudo de caso com profissionais da enfermagem. Rev Ciênc Admin. 2018;20(esp):117-29. doi: https://doi.org/10.5007/2175-8077.2018V20nespp117
  » https://doi.org/10.5007/2175-8077.2018V20nespp117
• 19. Aspiazu E. Las condiciones laborales de las y los enfermeros en Argentina: entre la profesionalización y la precariedad del cuidado en la salud. Trabajo Soc. 2017 [citado 2020 jun 01];(28):11-35. Disponible en: Disponible en: https://www.unse.edu.ar/trabajoysociedad/28%20DOSSIER%2002%20ASPIAZU%20ELIANA%20Enfermeras.pdf
  » https://www.unse.edu.ar/trabajoysociedad/28%20DOSSIER%2002%20ASPIAZU%20ELIANA%20Enfermeras.pdf
• 20. Randolph, SA. The Nursing Now Campaign. Workplace Health Saf. 2018;66(12). doi: https://doi.org/10.1177/2165079918805768
  » https://doi.org/10.1177/2165079918805768
• 21. Rao AD, Kumar A, McHugh M. Better nurse autonomy decreases the odds of 30-day mortality and failure to rescue. J Nurs Scholarsh. 2017; 49(1):73-79. doi: https://doi.org/10.1111/jnu.12267
  » https://doi.org/10.1111/jnu.12267

Edited by

Associate editor:

Dagmar Elaine Kaiser

Editor-in-chief:

Maria da Graça Oliveira Crossetti

Publication Dates

• Publication in this collection
  19 Oct 2020
• Date of issue
  2021

History

• Received
  06 Mar 2020
• Accepted
  19 June 2020