Abstract

Empowerment through decisional involvement among staff nurses is becoming an important approach in improving nursing systems in hospitals. Herzberg’s Motivation versus Hygiene Theory was used as the research framework with decisional involvement as a motivator.

Methodology

The research explored the relationship between the actual decisional involvement and work quality among staff nurses of a tertiary hospital using correlation research design. Two hundred fifty-seven randomly-selected subjects were surveyed using the Decisional Involvement Scale and Work Quality Index.

Results and Discussion

The findings revealed that staff nurses experienced low involvement in decision making when unit managers made resolutions in the areas of professional practice ( = 2.78), governance and leadership ( = 1.67), support staff practice ( = 2.15), and recruitment ( = 2.35). Sharing of ideas occurred between head nurses and staff nurses when decisions regarding unit staffing ( = 2.78) and collaboration/liaison activities ( = 2.94) were made. Participants were found to be moderately satisfied with their work quality in terms of professional work environment ( = 4.37), autonomy of practice ( = 4.99), work worth to self and others ( = 5.19), professional relationships ( = 5.07) and professional role enactment ( = 4.93). Minor dissatisfaction was perceived with the work benefits ( = 3.96) that the respondents receive. There was a significant positive relationship (r = 0.47,p < 0.001) between actual decisional involvement and work quality among nurses of the institution.

Conclusions and Recommendations

These findings supported Herzberg’s Motivation versus Hygiene Theory which states that contentment with work quality is influenced by intrinsic factors such as decisional involvement. The findings of this study can be used as bases in formulating shared governance strategies in healthcare organizations.

Keywords: nurses, empowerment, decisional involvement, work quality

Introduction

Over the years, the organizational culture of hospitals has been continuously modified to accommodate the growing number of services they offer. Different departments as well as new diagnostic/therapeutic equipment and personnel have been set up to cater the demands of the hospital clientele. Many procedures are formulated to stabilize the flow of departmental operations, opting health institutions to adopt a bureaucratic culture where decision making comes from different authorities. The situation now affects hospital processes with delays, placing service quality behind the number services that hospitals can offer,¹ creating inconvenience and inefficiency. ²

One key management principle, the Toyota Productions System, emphasized involving rank-and-file employees in the decision-making process to further the interest of the business organization, its customers and stakeholders. ³ Several studies in the business sector abroad have shown the positive effects of engaging employees in decision making. Empowered employees feel they are treated fairly in their workplace, ⁴ respond better to environmental changes ⁵ and able to correct service failures faster. ⁶ These results can be used as benchmarks to initiate improvement in the organizational culture of hospitals to promote better patient outcomes.

Work quality of nurses is used as a significant basis for retaining highly committed and experienced staff nurses. Operational impacts of high turnover rates in nursing units can result to diminished workgroup learning and lesser intimacy of work relationships^{. 7} The cost of recruitment, training, and potential errors of new staff nurses affects the resources of tertiary hospitals, altering the quality and economy of nursing care. Several determinants of work quality have been discovered. Professionalism, ⁸ good working relationships with superiors,⁹ and involvement in making decisions ^{10, 11} had made foreign health workers contented with their work quality. These evidences can now serve as bases for conducting similar studies among nurses in the Philippines, wherein the healthcare setting has always been challenged with economic hardships.

Therefore, this study aims to discover the relationship between the decisional involvement of staff nurses and work quality, so as to make staff performance and patient satisfaction better without increasing cost. This is to contribute comprehensive knowledge for institutional strategic planning and quality management. This study aims to answer the following research questions:

1. What is the extent of actual and preferred decisional involvement of staff nurses?
2. What is the extent of satisfaction with work quality of staff nurses?

Review of Related Literature

Decisional Involvement

Several researches had been implemented to explore the effects of employee empowerment. Five studies conducted among nurses and nursing assistants in different countries have tested Kanter’s Organizational Empowerment Theory to find out if the model will generate valuable institutional outcomes. Nurses in The Netherlands were more innovative, productive and effective in delivering healthcare services if informal relationships prevail in the workplace. ¹² Taiwanese nursing assistants were able to make meaningful actions when they receive more cooperation from co-workers.¹³ Chinese nurses feel that extensive professional training opportunities and involvement in decision making improved their job performance and satisfaction. ¹⁴ It has been established that lesser opportunities for professional growth and fewer access to information, resources, and support most likely wasted nurses’ efforts to achieve organizational goals. ¹⁵ Conversely, an empowered and civilized work environment had improved staff nurses’ job fulfillment and emotional burnout.¹⁶ Likewise, the results of a study on the work environment had revealed that American magnet hospitals were able to retain committed staff nurses through a more participative management style. ¹⁷ Employee empowerment in the business industry has demonstrated positive outcomes on job performance and satisfaction. Implementation of employee involvement in decisions fostered equity and good job attitudes,¹⁸ better organizational commitment,¹⁹ work optimism²⁰ and sense of work mastery and control.²¹

Work Quality

Antecedents of work quality had been identified in a number of studies. In-service trainings, length of service and civil status had positive influence on quality of nursing workplace.⁹ Clinical leadership²² and significant jobs with dynamic work designs²³ were also found to directly affect nurses’ contentment with the quality of their work. Job stress,²⁴ decency in professional relationships and faith,^{25, 26} had been attributed to better perceptions of quality of work. However, pay satisfaction does not always translate to work contentment as long as fairness is established in the workplace.²⁷ Empowering work conditions²⁸ as well as accessible organizational support²⁹ exhibited positive relationship with work quality. Workers in the Philippine business and government agencies had indicated that management style greatly influenced the quality of work.³⁰ Activities such as involving employees in decision making process coupled with effective leadership were most likely to influence fulfillment and commitment at work.^{31, 32}

Synthesis

The significant organizational outcomes of employee empowerment have been well established in a number of management system researches. Though these studies contribute a broad knowledge that explains the effects of employee empowerment, it seems that only few studies, especially in the Philippines, has explored the effects of involving nurses in the administration of their unit. The roles of economy, national/individual culture and organizational climate in the local healthcare setting has not been extensively studied. Consequently, these aspects would affect how well Filipino nurses are involved in the decision-making process of healthcare organizations. The available literatures only describe empowerment of nurses in a general sense, giving lesser comprehensions of staff nurse involvement in specific constructs of unit management. There are also few related studies on associating work quality with involvement factors; thus, giving fewer insights on strategies to improve empowerment and work quality locally.

Theoretical Framework

The Motivation Versus Hygiene theory, postulated by Frederick Herzberg, describes the different factors that affect work quality. Factors that positively affect contentment with the quality of work are referred to as motivation factors. These aspects are related to long-term innovations, psychological growth and self-actualization, which lead to overall contentment with work quality.³³ Motivators include achievement, recognition, the work itself, responsibility and advancement. In this study, the nature of decisional involvement is underpinned to the motivation factors responsibility and the work itself. The second group of factors in Herzberg’s theory is considered as hygiene factors, as they are commonly related to work dissatisfaction.

Methods

Design and Setting

This a non-experimental, cross-sectional, correlation research that explored the relationship between decisional involvement (independent variable) and work quality (dependent variable) of staff nurses. The study was conducted in a 592-bed tertiary hospital located at Manila, Philippines. Its nursing service department is comprised of 722 staff nurses, 39 head nurses, 13 supervisors and 1 chief nurse during the time the study was conducted. The nursing units of the medical center have similar organizational structure, staffing patterns and nursing care protocols.

Sample and Sampling Technique

Target population were all the permanently employed staff nurses of the institution who holds a bachelor of science in nursing degree. A written permission to acquire the master list of nursing personnel was coursed through the chief nurse. Given that there are 722 staff nurses employed at the time of data collection, the sample consisted of 257 staff nurses. Simple random sampling was employed to determine the participants for the study.  A total of 181 (70.43%) staff nurses completed the survey; while 76 (29.57%) of them did not return the questionnaires.

Instruments

The instrument for data collection was composed of three tools. The first tool was a questionnaire on the demographic characteristics that described the participants in terms of their employment status, type of nursing unit, length of experience and educational level.

The second tool was the Decisional Involvement Scale (DIS) which measured the actual and preferred level of decisional involvement of staff nurses. Developed by Dr. Donna Sullivan Havens, it is a 21-item psychometric tool used to measure the levels of staff nurse decisional involvement on six constructs in the administration of a nursing unit: unit staffing, quality of professional practice, professional recruitment, unit governance and leadership, quality of support staff practice, and collaboration/liaison activities. It is scored on a 5-point scale (1 for administration/management only, 2 for primarily administration/management – some staff nurse input, 3 for equally shared by administration/management and staff nurses, 4 for primarily staff nurses – some administration/management and 5 for staff nurses only). Content validity of the scale had produced indices of 1.0. The tool has exhibited high reliability (α = 0.91 to 0.95). A high score in the DIS means high degree of staff nurse involvement in decision-making, a low score means low degree of staff nurse involvement, and midrange score suggests sharing of ideas between the administration and staff nurses.³⁴

The third tool used was the Work Quality Index (WQI) by Whitley and Putzier. It is a 38-item questionnaire designed to measure nurses’ satisfaction on their overall work quality and in its six subscales: professional work environment, autonomy of practice, work worth to self and others, professional relationships, professional role enactment and benefits. Responses were scored on a 7-point scale (1 = very dissatisfied, 2 = dissatisfied, 3 = somewhat dissatisfied, 4 = neutral, 5 = somewhat satisfied, 6 = satisfied and 7 = very satisfied). Internal reliability of the entire WQI was established (α = 0.94). High mean scores denote better perceptions of work quality. Conversely, low mean scores translate to lesser contentment on the quality of work ³⁵. Written permission to use the DIS and WQI were obtained.

Data Collection Procedure

Coded questionnaire sets in envelopes were personally sent to staff nurses while they were on duty. They were asked to answer it for two weeks upon receipt. A written reminder on questionnaire completion was sent to their units one week before the deadline. The researcher personally collected these envelopes every afternoon for a two-week period.

Ethical Considerations

Written permission to conduct the study was obtained from healthcare facility. Likewise, ethical clearance was sought prior to the conduct of research. All respondents were informed about the purpose, benefits and risks of the study. A written consent was secured from the participants. They were given the right not to join the study. Coded questionnaires had ensured respondents’ anonymity. Only the researcher had an access to the sampling scheme and the responses gathered. Results of the study were not disclosed to anyone and were used solely for academic purposes and reported in the aggregate.

Data Analysis

Percentages were used to summarize the demographic characteristics of the participants. Mean and standard deviation of DIS and WQI overall and subscale scores were averaged. Pearson r was computed to determine the relationship between the two variables. The computed r value was tested for significance (α = 0.05). Likewise, a t-test to determine significant difference between the actual and preferred decisional involvement was done. Microsoft Excel 2010 was used for data management and statistical testing.

Results and Discussions

Demographic Characteristics

Most of the surveyed nurses (29.83%, n = 54) were assigned to medical/surgical units. Following closely were the participants who were assigned to intensive care units, which comprised of 24.86% (n = 45). Only 0.55% (n = 1) of them were assigned in the ambulatory care setting.  Majority of the respondents were those with 0 to 3 years of experience as registered nurses (56.91%, n = 103), as registered nurses (59.12%, n = 107), and as registered nurses in current unit (60.77%. n = 110). Conversely, participants with 16 to 19 years of experience as registered nurses (2.76%, n = 5), as registered nurses (1.10%, n = 2) and as registered nurses at their current unit (0.55%, n = 1) yielded the lowest percentage

Table 1 shows the mean actual decisional involvement of the participants were 2.78 for unit staffing, 2.35 for professional practice, 1.67 for recruitment, 2.15 for governance and leadership, 2.26 for support staff practice, 2.94 for collaboration/liaison activities and an overall score of 2.31.  These data show the participants’ low involvement in deciding for the critical issues of the unit. It can be reflected that the decisions in the nursing units are primarily made by the head nurses and/or supervisors. This is due to the fact that decisions in healthcare organizations need to be done immediately. Influence of the respondents’ characteristics can be also be observed in the low decisional involvement they experience. For one, majority of staff nurses have below three years of experience, which suggest that they were given fewer opportunities to decide for their unit. Another factor that affected this low involvement is the organization’s standardized management system, wherein staff nurses have to act within specified work instructions. They feel that they are intruding to their superior’s job if they give suggestion/ideas in the planning and execution of decisions for the unit.

On the other hand, the mean preferred decisional involvement of the respondents were 3.07 on unit staffing, 2.78 on professional practice, 2.23 on recruitment, 2.76 on governance and leadership, 2.84 on support staff practice, 3.16 on collaboration/liaison activities and an overall score of 2.78. These scores imply that staff nurses desire more opportunities in contribute to the decisions for their units. Though increased preferred involvement scores were observed, its actual value is not very high. One possible explanation is because staff nurses feel burdened with their tasks that they didn’t want to accept additional responsibilities. Also, nurses sometimes feel that the decisions made by their managers are already adequate.³⁶

Shared involvement in unit staffing was observed with mean score of 2.78. Decision-making in scheduling and unit coverage are shared by head nurses and their staff, having a mean actual involvement of 3.03 and 2.52 respectively. This implies that the organization promotes staff control of their time and nature of work without compromising the efficiency of their services.

Though staff nurses perceived shared decision making in practice standard development (2.51), staff nurses felt that defining (2.38), monitoring (2.25) and evaluating (2.26) their practice were mainly exercised by their superiors. The overall mean actual involvement of staff nurses of 2.35 – in this subscale – expresses that practice standards were developed mainly by the administrators and unit managers. One probable explanation is because the task of formulating standards is an executive function. Shared involvement was felt by staff nurses in developing practice standards because decisions on these matters emanated from the managers’ experiences as a rank-and-file employee wherein they could relate.

Staff nurses’ mean actual involvement in recruitment was low (1.67) placing recruitment (1.65), interviewing (1.49) and selection (1.87) of staff nurses as responsibilities of the management. This fact can be rooted from the policies and practice that the Human Resource Department determines the persons who will be hired. Interview and selection are also the department’s responsibility and staff nurse inputs are not required in these processes. Likewise, hiring new employees is traditionally a managerial obligation.

Mean actual involvement of the respondents was 2.15 in governance and leadership subscale. The mean scores for the following components of this subscale were: recommendation of disciplinary action for RN (2.09), selection of unit leader (2.04), review of unit leader’s performance (2.20), recommendation for promotion of staff RNs (2.21), determination of unit budgetary needs (2.04), determination of equipment/supply needs (2.29). Staff nurses experience low involvement in this administrative construct. It may be due to the fact that staff nurses perceive that more involvement in this aspect would incur additional burden on their part.³⁶

Staff nurse involvement in decision making on support staff practice had a mean of 2.26. The mean actual involvement in the development and monitoring of support staff standards were at 2.33 and 2.30 respectively. Likewise, mean actual involvement of staff RN in specifying the amount and type of support staff was around 2.17. Data gathered by this subscale narrates low involvement of staff nurses in decisions regarding this subject. This is possibly affected by the fact that monitoring the activities of support staff are conventionally done by managers. Another feasible explanation is the company’s implementation of a quality management system wherein specific jobs are assigned only to qualified persons.

Decision-making in the subscale of collaboration and liaison activities had a mean of 2.94. Staff involvement on liaison with other departments (2.58), professional relations with physicians (3.26) and conflict resolution on unit (2.99) depict a state of sharing in decision-making with their head nurses/supervisors. These data suggest that staff nurses are consulted by their unit heads when decisions regarding communication with other health professionals are deliberated. Findings in this subscale can be attributed to the nurses’ role as a liaison of the healthcare team. They function as a coordinator of the services of both medical and allied health professionals. Results on this specific subscale of the Decisional Involvement Scale are consistent with other reported literature.³⁶

Table 2 displays the overall WQI score of the participants and was found to be at 4.67. Contentment with other job-related factors was also measured: professional work environment was found at 4.37; autonomy of practice at 4.99; work worth to self and others at 5.19; professional relationships at 5.07; professional role enactment at 4.93; and benefits at 3.96. Nurses who joined the study are moderately satisfied with the work quality as the role of job characteristics, work worth and professional relationships contributed to this rating. These findings were similar with two researches.^{37, 38} The lowest satisfaction is with benefits, wherein nurses look for well-rounded benefit packages when compensation does not meet their expectations.³⁹

Work quality index of professional work environment was 4.37. The staff nurses satisfaction with participation in policy making for nursing service was 3.83; opportunity for advancement at 4.55; opportunities for personal growth at 4.88; praise from nursing administration at 4.23; in-service opportunities at 4.30; supportive organizational structure regarding patient care at 4.83; and respect from nurses on other units at 4.74. Data suggest that staff nurses moderately satisfied in this aspect of their job except in the areas of policy formulation of the hospital and nursing service can still be improved ^{28, 29}. This is consistent with their low actual involvement scores.

Mean index of work quality with autonomy of practice is at 4.99. This also shows their satisfaction with making necessary practice adjustment (5.16), making autonomous care decisions (4.96), having a stimulating intellectual environment (4.81), being accountable with their actions (5.01), and a developing a high level of clinical competence (5.01). These data imply that nurses are moderately satisfied with their role performance in the healthcare organization. ¹⁷

Noticeable is a moderate contentment with the worth of their work (5.19). Staff nurses expressed positive work quality with the ability of their work to contribute to the hospital (5.02), profession (5.27), and personal achievement (5.23), as well as when their work allows them to use full range of skills (5.24). Findings are suggestive that nurses view their profession and role as critical parts of the hospital operations.^9,23

Work quality of staff nurses with their professional relationships in the organization is observed at 5.07. Satisfaction with these aspects of professional relationships include receiving support for nursing decisions from physicians (4.77), peers (5.36), and nurses from other shifts (5.21); having good work relations with physicians (4.88), peers (5.58) and supervisors (5.62); and adequate praise from physicians (4.53) and peers (5.23). Moderate satisfaction is experienced by staff nurses when it comes to their professional transactions. They find communication as the best thing about their job ⁴⁰ and as the source of their work motivation. ⁴¹

Professional role enactment among staff nurse is at 4.93. Nurses rated satisfaction with completing physical care tasks at 4.82, completing indirect care tasks at 4.71, various clinical challenges at 5.31, adequate time for research at 4.21 and opportunity to serve others at 5.62. Data depict staff nurses’ moderate satisfaction in performing the roles associated with their respective task. It can also be noted that satisfaction with research time got the lowest score. Probable cause for this is organization’s non-prioritization of research, as stated in the scope of their quality management system. Secondly, research guidelines were not established, which places the process unclear.

Contentment with the benefits that the participants received was at 3.96, additional financial benefits at 3.12, salary at 2.76, directions with advancement at 4.51, funding for healthcare at 3.35, fair decisions regarding advancement at 4.49, work pattern at 4.18, number of sick leave at 4.73, and adequate 4.55. Evidently, staff nurses are dissatisfied with the monetary benefits that they receive. This is consistent with research findings that illustrated employee dissatisfaction caused by unsatisfactory salary and inadequate financial benefits other than salary.²⁷ Attributable causes for this finding are the private institutions’ compliance to the minimum wage for employees as stated in the labor code and the exclusive applicability of the wage standardization law to government agencies. However, perceptions of satisfaction with non-monetary packages are moderate, indicative of contentment among surveyed nurses.

Relationship of Decisional Involvement and Work Quality

Pearson r reveals that the correlation coefficient of actual decisional involvement and work quality is at 0.47. This means that a moderate positive relationship exists between the two factors, indicating that an increase in the decisional involvement of staff nurses would also increase their contentment with quality of their work.

Setting the level of significance to 0.05, it can be established that there is a statistically significant relationship (p < 0.001) between actual involvement and work quality of nurses. This result follows Herzberg’s theory of motivation versus hygiene factors stating that motivation factors, such as decisional involvement, directly nursing work quality. Additionally, empowering nurses in the workplace has been identified as a positive influence of their quality of work in several nursing systems research.^16,38,42

Difference between the Actual and Preferred Involvement

Placing the level of significance at 0.05, the findings show that there is a significant difference between actual and preferred involvement of staff nurses. Though preferred involvement level is not too high, this statistically significant value clearly explicates that staff nurses wanted to partake in the decision-making process of their units at only a certain level, like work delegation and control of staff performance monitoring. This discovery was also observed in researches that explored decisional involvement of foreign nurses. ³⁶

Conclusion and Recommendations

Consistent with the outcomes of this research, it can be concluded that staff nurses’ actual decisional involvement has a statistically significant positive relationship with their work quality. When an increase in the access to resources (e.g. man, materials and knowledge) occurs, a positive impact would affect work characteristics. Therefore, decisional involvement is an essential component in improving the quality of work. Utilizing the findings of the study, a number of recommendations are proposed:

• Open dialogue with staff nurses to assess and discuss their preference in decisional involvement.
• Assess practices in hospital policy making to see if current provisions would allow staff nurses to be involved in the decision-making process.
• Develop and implement policies that would allow staff nurses’ input in major management planning and evaluation activities such as organizational strategic planning, regular management reviews on institution’s performance, appointing them to quality audit teams/committees and other similar activities.
• Review existing guidelines and practices in making decisions for the unit and amend them to facilitate input of staff ideas.
• Encourage nurse supervisors and head nurses to solicit staff nurse inputs in critical decisions that affect them to keep their interest and involvement in the process.

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