Structural empowerment of nurses in the hospital setting

Objective: to measure the level of structural empowerment of nurses working in a university hospital. Method: a descriptive, analytical, and cross-sectional study, carried out with 237 nurses, who developed care and management activities. Data collection took place through a self-administered questionnaire with questions on the personal and professional characterization and the Work Effectiveness Conditions Questionnaire II. Data analysis used descriptive and inferential statistics. Results: it was identified that nurses have a moderate level of structural empowerment (18.06±SD 0.9). The greatest value was obtained in the Opportunity dimension (4.08±SD 0.8), followed by the Resources (3.17±SD 0.8) and Informal power (3,04±SD 0.9) dimensions; while the scores of Support (2.67±SD 1.0), Formal power (2.59±SD 0.9), and Information (2.51±SD 0.9) were lower. Conclusion: the level of structural empowerment of the nurses was moderate, which means partial access to opportunities, resources, support, and information of the institution.


Introduction
The hospital work environment is constantly changing to keep up with technological advances and to develop strategies aimed at providing quality and safe care to the patients (1) . This scenario requires health workers to be proactive and to constantly seek professional updating and development, especially by nurses (1)(2) .
In the context of the organization of hospital work, nurses are responsible for the management of care and of the nursing services, which involves the development of leadership practices, conflict management, staff sizing, provision and forecasting resources (2) . For the proper performance of these actions, it is important that the organizations adopt models and management policies that enhance the empowerment of nurses (3)(4) .
In general, empowerment is the process by which individuals strengthen or develop skills to promote positive changes in the context in which they are inserted. In the nursing literature, empowerment is used as a comprehensive concept to describe elements of professional growth and development (4) .
Structural empowerment refers to the ability to mobilize resources and achieve goals through access to information, support, resources, and opportunities.
Access to information refers to the knowledge of organizational changes and policies, as well as to the technical knowledge necessary to carry out the work.
Nurses gain access to support by receiving feedback and guidance from subordinates, colleagues, and superiors, which enables autonomous decision making. Access to resources involves the nurses' ability to obtain the supplies, resources, and materials needed to achieve the organizational goals. The opportunities refer to the possibilities of learning and professional development of nurses (5)(6) .
Psychological empowerment is the worker's psychological response to empowerment arising from working conditions, which generates motivation and contributes to the sense of personal control in the workplace. In Nursing, psychological empowerment involves the perception of the professional about the valorization of their work and their contributions to contribute to the care processes, which leads to a feeling of competence and freedom. Thus, structural empowerment leads to nurses' psychological empowerment (6)(7) .
Thus, the empowerment of nurses contributes to greater professional satisfaction, decreased burnout rates, and increased autonomy and organizational commitment. In addition, it positively impacts patient safety and quality of care in the health services (3)(4)(6)(7)(8) . As a result, it is necessary for the managers to be attentive to their organizational practices, since just ensuring the quality of the technical aspects of processes or services is no longer sufficient to maintain the efficiency of organizations, and it is also necessary to invest in the involved people (9) .
A number of studies on the structural empowerment of nurses have been developed in several countries in the last decade, mainly the United States of America, Canada, China, United Kingdom, Germany, Italy, Spain, and Portugal (4,(10)(11) . In Brazil, this theme is still incipient, despite the recent growth of research on nurses' working environment (12) .  (10) .
The CET-II is an instrument of public domain, which aims to measure components of structural empowerment found in the nurse's work environment (13) .
It consists of 21 items, divided into six components: (1) Opportunity -feeling of challenge and opportunity to learn and grow, (2) Information -data, knowledge and experience, awareness of the organization›s objectives perceptions of empowerment (14) . The internal consistency of the scale was assessed by the Cronbach's alpha coefficient, which was calculated for each of the subscales and for the total items of the instrument. In this study, the alpha value was 0.7 for the scales of opportunity, resources, and formal and informal power. The information and support scale was 0.8 and the total number of items in the CET-II was 0.9. It is noteworthy that the Cronbach's alpha value can vary from zero to one. Thus, the higher the value, the greater the internal consistency of the instrument (15) .   (Table 1).  Table 2.   (Table 4).

Discussion
In this study, the sample of nurses was predominantly female, with a partner. These are similar results to other national (12)(13) and international (17)(18) surveys.
In relation to vocational training, most of the nurses had graduate degrees being lato sensu or stricto sensu, which corroborates earlier research outcomes (18)(19) . The professional has been increasingly seeking professional qualification in order to expand knowledge and meet the demands of the labor market. The continuous search for improvement and updating is essential for the professionals in view of the complexity of procedures and increasingly innovative technologies in the hospital context (20) . Regarding empowerment, this data is extremely relevant, because empowering implies having knowledge, attitudes, and ability to efficiently perform their role.
In this study, the participants have a mean experience of 13 years as nurses. On average, the professionals have worked at the institution for eight years and their mean experience in the sector was 4.9 years. These results were similar to those of other studies found in the international literature (18)(19) .
No studies were found that specifically linked empowerment to professional practice time. However, it is believed that the greater the experience, the greater the empowerment, which allows reading this result in a positive way. Newly graduated nurses often face challenging and stressful situations at work, as they are not always able to successfully complete their activities or receive support to perform certain care actions. This happens not only due to lack of skill, but also due to fear and common insecurity at the beginning of professional life (21) .
As for the total mean of the CET-II, the nurses showed a moderate level of structural empowerment.
Regarding the domains of empowerment, access to opportunity was the component with the highest mean, followed by the resource and informal power components. The information domain had the worst mean, followed by formal power and by support. These results are similar to a study carried out in Portugal in which the "opportunity" and "informal power" domains had better evaluations and the "formal power" and "information" domains also had worse evaluations (22) .
In this study, the results showed that nurses have opportunities to learn and grow professionally, within the work environment. Similar results are described in previous studies using the same instrument, reinforcing that the opportunity to learn and grow at work implies the use of personal skills, promoting a sense of selfefficacy and autonomy (17)(18)(19) .
When comparing the nine sectors by domain, a significant difference was identified in the opportunity domain, between the emergency room and ICU sectors.
That is, the nurses in the emergency room have more have an intense activity, they are dynamic environments, constantly changing, that attend complex patients and those at risk, demanding a lot of responsibility and commitment from the professionals. In addition, in these units, assistance must be provided through teamwork, in which multiple knowledge and skills need to come together to plan, organize, and define strategies that bring better results to the patients (23) .
The emergency room of the researched institution is a reference in urgent and emergency care for a population of more than one million inhabitants.
It is the gateway to the hospital service and a place where people seek quick resolutions to health-related problems, when they cannot get resources in primary health care (24)(25) . It is also noteworthy that the high complexity and unpredictability of the services in this location require the professionals to have a high level of training and the nurse is an important figure, as coordinator of the care team (26) .
It is an instigating environment, as it is not limited to a patient and severity profile, making the professional always up to date and seeking knowledge, due to the various types of pathologies that patients have (25)(26) .
Thus, these characteristics make nurses look for more opportunities for growth, learning, and knowledge in this sector.
In the hospital setting, nurses have moderate resources, which corresponds to the time to carry out the bureaucratic work, materials, and equipment necessary to achieve the organizational goals and to fulfill the work requirements (1,12) . The sector that obtained the best score in this domain was hematology-oncology. It is a specific area of activity, where there is a restricted team and the nursing work is characterized by assistance that involves, in addition to care practices, characteristic situations, such as the specificity of the treatments used and the presence of sensitized patients, with biggest limitations (10) . As such, this result can be attributed to several factors, as the institution is a reference in hematology-oncology care, there is a greater possibility that it will follow several safety standards in care, better structure, more resources and equipment, which can offer better conditions for professionals.
An international study conducted with nurses working in intensive care environments revealed that access to the resources was the domain with the lowest score, mainly due to financial restrictions (17) . Resource limitations challenge hospitals to improve their quality of performance and to increase the safety and effectiveness of patient care, without providing the best conditions for this (4) .
Based on the findings of this study and on the related literature, the hypothesis is raised that nurses with resources and equipment available to provide assistance and management, as well as knowledge of the whole, tend to be more empowered at work, especially psychological empowerment. In addition, in relation to support, the results showed that nurses have moderate support from colleagues and supervisors within the work environment, as well as the resolution of problems and improvements related to work. In this environment, nurses receive feedback on the work performed, as well as guidance from their colleagues, subordinates, and superiors. The more feedback and guidance that the professionals receive from leaders and superiors, the greater the job satisfaction will be (27) .
It is worth mentioning that, within an organization, power results from formal precepts (activities that allow for the achievement of organizational objectives) and informal precepts (derived from interpersonal relationships) that allow access to structures that promote empowerment (18) . Job satisfaction tends to be higher when you have high levels of empowerment, as well as when you have higher levels of formal and informal power (28) .
Although the information domain was moderate, it obtained the lowest value in the investigated location.  (29) .
Another important data pointed out in the present research is related to the fact that the psychiatric sector obtained the best score in terms of access to information, support, formal and informal power. This place demands agility and attention during the service from the professionals, as well as the accomplishment of team work, planning and organization of the activities, and also a specialized technical preparation for better performance in the care of patients (30) . An international study also highlights the importance of nurses' empowerment for a positive patient safety culture (31) . Therefore, it should be noted that managers and nursing leaders must ensure the empowerment of nurses in order to increase the quality of patient care in the hospitals (28) .

After the validation of the CET-II for use in
Brazil, this is the first study to apply it among nurses