For Beverly Malone, RN, PhD, FAAN, the empowerment of nurses is much more than an esoteric theory to help RNs feel better about themselves; it’s requisite for the delivery of quality patient care.
Malone, the CEO of the National League for Nursing based in New York City, experienced firsthand how empowerment could change a patient’s outcome when she was a staff nurse caring for a 16-year-old girl with bone cancer. A resident surgeon had scheduled a procedure to amputate the patient’s legs, but Malone knew the girl wanted to keep her limbs during the time she had left. When the surgeon did not change his decision after hearing this, Malone sought out several managers to advocate for the girl. In the end, her persistence paid off. The surgery was canceled, and the girl was relieved.
Malone describes empowerment as the ability to authorize oneself to act in the pursuit of safe, quality, patient-centered care. She is among a growing cadre of nurse leaders and researchers who are spreading the message that nurses need to recognize the power they have to affect change by mobilizing resources or people to deliver the best care to patients. Failing to do so can cultivate a sense of powerlessness, which can have dramatic implications on the quality of care nurses deliver and, ultimately, on whether they decide to stay in the profession say nursing experts.
But there is hope, according to Malone. “If you ask nurses how much power they have, most will say that they do not have a powerful position,” she said. “But I believe that helping someone to live is one of the most powerful jobs in the world. If we can recognize this power, then we can manage it in a healthy, effective and caring way.”
Results of powerless attitudes
Catherine Garner, RN, DrPH, MSN, MPA, FAAN, dean of health sciences and nursing at Aurora, Colorado-based American Sentinel University, suggested harboring a sense of powerlessness ultimately can lead to an ethical dilemma for nurses.
“When nurses feel that they can’t control their environment or influence the direction an organization is going, they can become dissatisfied,” Garner said. “There are studies that show that nurses who are dissatisfied do not deliver the best quality of care, and that leads us to an ethical question: If nurses are not satisfied professionally, how in good conscience can hospital leaders feel that they are giving the best care?”
Linda Aiken, RN, PhD, FRCN, FAAN, professor in the University of Pennsylvania School of Nursing in Philadelphia, is one of several researchers who examined survey data from more than 95,000 nurses in four large states to explore job satisfaction levels. The February 2011 study published in Health Affairs, found nurses providing direct patient care in hospitals or nursing homes had a much higher job dissatisfaction and burnout rate than nurses working in other settings, such as the pharmaceutical industry. Aiken has conducted other studies that suggest this dissatisfaction results in reduced quality of care and poorer patient outcomes.
Nurses who feel powerless also are at risk of directing their frustration at co-workers, Garner said. “It can lead to lateral violence,” she explained. “If a nurse is angry about something, then he or she may take this out on co-workers who are not really able to do anything to change the situation. Frustrated nurses are also more likely to complain to one another, but none of these behaviors solve the problem.”
Researchers also are discovering lack of empowerment is linked to a nurse’s decision to leave a job or abandon the profession. Joyce Zurmehly, RN, PhD, DNP, associate professor at Ohio University-Chillicothe, was eager to explore the correlation. After surveying more than 1,300 nurses in Ohio, she found nurses in the study experienced only moderate levels of empowerment. Those who perceived higher levels of empowerment were less likely to exit the profession. Only 25% of nurses with a high-to-moderate perceived level of empowerment indicated a good chance of leaving their position, while 75% of nurse respondents having a less-than-moderate perceived empowerment said they were likely to leave.
Overcoming the power complex
Although there are serious implications for feeling powerless in nursing, learning to use power is not as easy as turning on a switch, Malone acknowledged.
“Using your power is sort of unnatural,” she said. “It takes practice, but the reward is that it will help us mature into true professionals.”
One of the first steps is recognizing that power is not negative. Instead, Malone said, families are looking for someone who is empowered to help them navigate an overwhelming healthcare system and come out on the other side as healthy or peaceful as possible.
The next step, Garner said, is to take responsibility if there are things that could be improved. Ideally, nurses could go home and conduct research online to learn about the best practices for something they want to change, and then select the right person — and the right time — to share the idea.
“Oftentimes, the person who can move the agenda along the best is a powerful physician,” Garner said. “If you have an innovative idea, approach [that] physician and say something like ‘I work with a lot of your patients and I did some research, and here is something we could do differently that might benefit patients. What do you think?'”
The next step is to make time to volunteer on committees, conduct a pilot study or talk to nurse colleagues who need to champion the idea to others.
“I think it’s also important to align yourselves with people you respect who know how to move things forward,” Garner said. “They can teach you how to phrase things and how they have successfully brought about strategic changes.”
Chris Kowal, RN, MSN, CCRN, SICU staff nurse at St. Joseph’s Hospital Health Center in Syracuse (N.Y.), discovered a year ago just how satisfying it is to drive positive change. He was aware the unit was using a pain assessment tool geared for adults with dementia, but the scale was not an accurate one for the temporarily nonverbal postsurgical patient population that was a high-volume group in that unit.
“I didn’t consider myself a force for change, but I knew it was important to make a change because it was the right thing for patients,” Kowal said.
He sought out a clinical nurse specialist who was familiar with the process involved in implementing change, and his colleague encouraged Kowal to conduct a literature review of pain assessment tools.
“I had to deal with committee upon committee to explain the current state of affairs and what we were finding in the literature, and then I discovered we had to conduct a pilot study to test the new tool,” he said.
Kowal admitted he was frustrated by what seemed like barriers, but the results of the pilot study solidified his resolve. He found the unit achieved better pain management ratings with the new tool, and when patients were in less pain, they were able to be weaned off ventilators more quickly.
“This experience showed me that you can make changes as a bedside caregiver, and you do not have to be a manager,” Kowal said. “The bottom line is that everyone is a leader, and now many bedside nurses in our hospital are making changes because they know it’s possible.”
Nurses who take steps to initiate change also will discover organizations may be increasingly open to their ideas, Garner said. The combination of empowered nurses and open-minded hospital leaders could usher in a new climate for change.
“We are in very unique times when Americans realize that we have limited resources to take care of sick people,” she said. “We have to figure out how to provide the best possible care while minimizing costs, and this is creating an openness among hospital leaders that I have not seen in 30 years. It is a time when nurses — who have more knowledge of what happens day-to-day — need to speak up.” •