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Introduction
Patient safety, as defined by the National Patient Safety Foundation, is the avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of health care (National Patient Safety Foundation, 2016, para. 12). Patient safety is an expected characteristic of hospital stays. Although patients, their families, and health care providers expect hospital care to be safe, medical errors in U.S. hospitals result in more than 400,000 patient deaths annually (James, 2013). Nurses are well positioned to assess changes in patient conditions and prevent treatment errors (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002). Nursing professionals vigilance at the bedside is essential to safeguard patient care and to detect medical errors such as incorrect medication orders (Aiken et al., 2002). For bedside nurses to provide safe patient care, nurse executives must actively and continuously promote a culture of patient safety. Such a culture ensures that bedside nurses are empowered to perform their roles and are given the resources necessary to fulfill their responsibilities in a safe manner (Aiken et al., 2002).
Empowerment
Alsop and Heinsohn (2005) have described empowerment as the development of an individual or a groups ability to actualize choices. This definition has two components: a process through which individuals become empowered and an outcome in which individuals have acquired an ability to actualize choices as desired actions or outcomes (Alsop & Heinsohn, 2005, p. 5). In hospitals, empowerment is closely linked to safe patient care. In the delivery of such care, empowerment plays a pivotal role in creating a practice environment that is productive and healthy for both patients and care providers (Greco, Laschinger, & Wong, 2006). In acute care hospitals, a conducive environment for empowerment can facilitate the delivery of safe patient care and decrease the breakdowns in safety that currently exist in health care, as evidenced by the alarming number of medical errors in the United States. Greco et al. (2006) revealed a strong correlation between empowerment of nursing professionals and the level of their burnout (as well as job fit) that was regarded as one of the primary factors contributing to the increase in errors in the clinical setting. Richardson and Storr (2010) implemented a review of studies that also showed the link between empowerment and medical errors. The studies mentioned proved that the number of medical errors was smaller when nursing professionals were able to make decisions concerning some aspects of patients treatment (for example, injections).
The Nurse Executive Role
In acute care hospitals, nurse executives such as chief nursing officers and nurse directors provide leadership by coordinating the operational components that are essential for patient safety: a culture of safety; adequate planning for care and services; resources (human, monetary, physical, and informational); staffing and resources to assure staff competency; and a commitment to performance improvement (Schyve, 2009). The diverse responsibilities of nurse executives also include strategic leadership for all nursing and other designated patient care functions and services, fiscal management of patient care, and compliance with objectives and strategies for the provision of safe, high-quality care (Englebright & Perlin, 2008; Frederickson & Nickitas, 2011; Havens, Thompson, & Jones, 2008).
Empowerment of Nurse Executives
Because both nurse executives responsibilities and health care itself are so complex, nurse executives must be empowered to perform their leadership roles (Mathena, 2002). Empowerment enables nurse executives to facilitate the delivery of safe patient care by their professional actions (e.g., rounding on direct reports and providing equipment needed for patient care) and their personal behavior (e.g., respectful communication that welcomes staff concerns) to influence co-workers such as bedside nurses. By virtue of their position in hospital organizations, nurse executives can create a work environment that is conducive to nurse empowerment and patient safety. To create such an environment, nurse executives themselves must feel empowered (Greco et al., 2006).
Purpose of Integrative Review
In this integrative review, I will (a) discuss current knowledge and gaps in knowledge on the empowerment of nurse executives, (b) clarify how empowerment of nurse executives and staff nurses relates to self-efficacy and patient safety, and (c) propose how this research can enrich knowledge in the field of patient safety.
Background and Significance
How the presence or absence of nurse executive empowerment influences the delivery of patient care is the core issue. In becoming empowered, nurse executives must develop administrative judgment, sensitivity, and self-confidence, cognitive and affective abilities that are critical for leaders in acute care hospitals (Greco et al., 2006). Through empowerment, nurse executives can structure work environments that enable their nurses to deliver high-quality patient care, achieve high patient satisfaction scores, and produce positive patient outcomes (Mathena, 2002). In acute care settings, the responsibilities of nurse executives are extensive and consequential (Greco et al., 2006; Platt & Foster, 2008).
Nurse executives are pivotal in directly or indirectly creating organizational goals and expectations that influence patient safety. To achieve such goals, they must foster hospital relationships in ways that build and maintain trust while inspiring the commitment of others to achieve organizational goals (Englebright & Perlin, 2008; Frederickson & Nickitas, 2011; Havens, Thompson, & Jones, 2008). Trust among hospital staff is a key element of a patient safety culture and maintenance of the proper working environment (Hughes, 2008). Healthcare professionals can collaborate effectively as trust facilitates honest and open communication that encourages nurses to notice safety flaws, real or potential, and take corrective or preventive action. Auer, Schwendimann, Koch, Geest, and Ausserhofer (2014) found that nurses trust in hospital management contributed to the improvement of patient safety as nurses trusting their leaders could openly share their experiences, discuss errors made and ways to prevent and address them. The researchers stressed that open communication was one of the outcomes and, at the same time, the ground for the development of trusting relationships among healthcare professionals. The open discussion facilitated learning that translated into the development of effective methods and strategies associated with corrective measures.
In executing their responsibilities, nurse leaders must model behaviors and set expectations that empower nursing professionals to support patient safety (Schyve, 2009). Such actions include partnering with physicians to develop patient placement criteria that ensure assignment to the right level of care. When nurse leaders model behaviors like respectful communication, they demonstrate professionalism that can empower bedside nurses to voice concerns about patient safety without fear of humiliation or retribution (Schyve, 2009). Finally, when nurse executives champion patient safety as their hospitals priority, they promote a culture of safety and a safe working environment. My dissertation will explore the relationship between the empowerment of nurse executives and an environment that facilitates the delivery of safe, quality patient care.
Theoretical Approach
Researchers have used a number of theoretical frameworks to address such issues as patient safety and nurses empowerment. Normal accident theory (NAT) and high reliability theory (HRT) enable health care professionals to understand patient safety and develop highly reliable organizations (HROs; Cooke, 2009). According to Perrow (1999), organizations (be it a nuclear power plant, laboratory or hospital) are complex systems consisting of various components that may interact in different ways. These interactions tend to result in emergency situations, which makes accidents inevitable, even normal (Perrow, 1999, p. 4). It is often difficult to prevent the occurrence of accidents as the characteristics of the components and especially the ways they can interact are often insufficiently researched due to the substantial number of components and variations of their interaction. The clinical environment can be regarded as one of these complex systems highly vulnerable to accidents. Each of the accidents can result in negative health outcomes for patients.
In the clinical setting, the NAT has been widely applied while some researchers regard it as a pessimistic paradigm. For instance, Haavik, Antonsen, Rosness, and Hale (2016) claim that the theory focuses on sociotechnical aspects and implies low chances of addressing risks effectively. Nevertheless, the theory is instrumental in managing high-risk accidents as it unveils characteristics of the systems that are at risk. Perrow (1999) argues that such measures as duplication, decentralization and continuous learning (and training) can help organizations prevent numerous accidents and mitigate the outcomes of emergencies that have taken place. Schwappach, Pfeiffer, and Taxis (2016) used this theoretical approach to address patient safety issues in clinical practice and found that duplication (double-checking) was seen positively by nursing professionals who believed that the practice contributed to the decrease in medical errors.
The high reliability theory was created as a response to the rather pessimistic NAT. Cooke (2009) states that some organizations have successfully managed risk and they can be referred to as high reliability organizations. HROs continuously improve performance by creating system solutions quickly to resolve organizational problems (Cooke, 2009). The primary features typical of HROs include the placement of safety at the center, which presupposes a lot of training and ongoing learning. Another feature of the HRO is the development of informal networks and flexibility. Finally, HROs build in redundancies that can back up failures of individual components that can result in the prevention of systemic errors (Cooke, 2009, p. 260). In simple terms, in HROs, people focus on safety, train and learn from their past experiences to prevent and manage high-risk accidents. At the same time, the high reliability theory is associated with a number of flaws as it underestimates such external factors as political influences and fails to pay the necessary attention to the underlying reasons for accidents (Cooke, 2009). Another weakness of this theoretical paradigm is that it implies an easy change in the organizational culture from the top. Therefore, researchers note that practitioners should mind these peculiarities (strengths and weaknesses) when applying the HRT or NAT (Cooke, 2009).
It has been acknowledged that culture of patient safety that is informed by the NAT and HRT leads to positive patient outcomes such as (a) decreased mortality rates; (b) decreased hospital-acquired pneumonias, infection, and pressure ulcers, (c) decreased rates of failure to rescue, (d) minimal opportunities for medical errors to occur, and (e) increased patient satisfaction (Feng, Bobay, & Weiss, 2008). Health care organizations that promote patient safety must begin with nurse executives who promote a culture of patient safety.
Two theories, Kanters (1977) theory of organizational empowerment and Banduras (1977) theory of self-efficacy, offer a theoretical basis for understanding empowerment. The aim of this study is to examine the correlation between empowerment, self-efficacy, and patient safety. Therefore, it is critical to pay the necessary attention to theoretical paradigms used by researchers exploring self-efficacy and empowerment with the focus on the clinical setting. Kanters theory discusses the structural determinants of empowerment. Banduras theory is often applied when researchers and practitioners try to understand, develop, and optimize nurse executive behaviors that promote empowerment.
Empowerment to improve patient safety requires that staff nurses excel in their role and responsibilities (e.g., advancing from bedside to supervisory roles, presenting in-service programs to colleagues, and exhibiting autonomy in direct patient care) and have the knowledge to perform tasks, the information to complete jobs, and access to required resources (Kanter, 1977). In addition, the empowerment of nurse managers (midlevel management) requires the support of their superiors (i.e., nurse executives) to facilitate the achievements of frontline nurses as well as their own achievements (e.g., role autonomy, authority to order equipment for patient care, opportunities for promotion, and opportunities to promote their staff). These factors not only strengthen employee engagement in their work but also promote job satisfaction. Kanters (1977) concepts of organizational empowerment, which were derived from actual organizations, are applicable to health care organizations.
Banduras (1977) theory of self-efficacy can elucidate the dynamics that influence human behavior. In this theory, self-efficacy is defined as ones belief in ones own capability to succeed in such courses of action needed to attain or influence an outcome (Bandura, 1977). Fundamentally, people have the ability to influence their own actions and outcomes (Smith & Liehr, 2008). For self-efficacy to develop, one must be capable of assessing ones behavior and beliefs about what one can accomplish (Smith & Liehr, 2008). Beliefs about self-efficacy, according to Bandura (1997), constitute the key factors of human agency (p. 3). High self-efficacy has a positive effect on behavior (Smith & Liehr, 2008). Conversely, an individuals belief that she or he cannot change outcomes will reduce the likelihood that they will engage in or persevere in behaviors to produce results. The achievement of positive patient outcomes requires that frontline nurses believe in their care assessments and abilities. Leaders too must believe in themselves and their ability to influence frontline nurses to deliver safe patient care.
Organizational theorists have identified several leadership practices that increase self-efficacy (Conger & Kanungo, 1988). Leaders who express confidence in nurses and provide them with opportunities to make or take part in practice decisions create an empowering environment. To create an organization whose policies and practices are empowering, nurses must be knowledgeable of their own self-efficacy (Congor & Kanungo, 1988). Conceptually, nurse executive leaders must believe not only that they can effect change but also that they are able to do so.
Self-efficacy applies to other behaviors that can promote patient safety. Acute care environments in which nurses are encouraged, respected, and praised for voicing safety concerns, without fear of retribution, is conducive to open, honest communication. Such communication fosters greater involvement in decisions about patient care and the environment in which they provide care (Havens & Aiken, 1999).
Kanter (1977) and Banduras (1977) conceptual frameworks guided this integrative review, elucidating the concepts of empowerment and self-efficacy as they pertain to patient safety in acute care settings. Using these frameworks, I identified literature that discusses the concepts (i.e., empowerment in organizational settings, engagement in work environments, behaviors that promote ones ability to deliver safe patient care, and a culture of patient safety) and relevant terms (i.e., nurse leader, empowerment, nurse self-efficacy, patient safety) that are key to understanding the phenomenon of empowerment at the nurse executive level.
Integrative Literature Review
In the light of nurse executives central role in acute care hospital operations and the importance of institutional empowerment, a clear understanding of nurse executive empowerment will better explain the relationship between empowerment in the clinical environment, patient safety, and the delivery of quality care. To date, nurse executive empowerment has not been thoroughly studied. The purpose of this integrative literature review is to analyze studies of the effect of empowerment on patient safety.
Aims of the Review
The aims of this integrative review were (a) to analyze how the concept of empowerment has been used in nursing research and theory, (b) to discuss research on how empowerment of nurse leaders and frontline nurses has affected patient safety, and (c) to discuss research that demonstrates the relationship of nurse self-efficacy to patient safety. This analysis will present current knowledge on these topics and reveal gaps in knowledge that I will address in my dissertation.
Methods
An integrative review of health-related literature was conducted using Whittemore and Knafls (2005) five-step process: problem identification, literature search, data evaluation, data analysis, and presentation.
Problem identification
An excessive number of errors occur in hospital settings every year. Facilitating the empowerment of nurse executives and other nurses has the potential to decrease those errors and facilitate safety. This review aims at examining the most relevant findings, as well as methodologies and theoretical paradigms used to implement research, associated with the correlation between patient safety and nurses empowerment.
Literature search
The focus of this search was nurse executive empowerment, patient safety, and nurse self-efficacy in health care settings. A search of the CINAHL, PSYCHInfo, and PubMed databases using MeSH terms yielded 1,665 articles of interest. Iterative searches using a combination of other MeSH terms reduced the number of relevant articles to 252 (see Appendix A).
Data evaluation
Data from theoretical and empirical literature were reviewed (Whittemore & Knaff, 2005). A wide variety of research methods (e.g., mixed methods, survey questionnaire, and longitudinal design) were selected, and the articles to be reviewed were organized in table format for further analysis.
Data analysis
The research articles on nurse empowerment, patient safety, and self-efficacy were grouped by theme to allow for easier categorization and analysis (Whittemore & Knaff, 2005).
Presentation
Table 2 presents the findings of this review. The sample size, design and instrumentation, theoretical framework, major findings, generalizability, and strengths and limitations for each research article are found in Appendix B.
Quality Appraisal
This literature review relied on the guidelines for research evaluation developed by Pluye, Gagnon, Griffiths, and Johnson-Lafluer (2009) and Pluye et al. (2011). The criteria for quantitative studies included institutional review board (IRB) approval, a description of variables and methods, and logical data collection and analysis (Pluye et al., 2011). In addition, the appropriateness of measurement tools (i.e., clear origin, known validity, or a reliable standard instrument), sampling strategy, and sample under study were evaluated (Pluye et al., 2011).
The criteria for qualitative studies included IRB approval, participant informed consent, credibility, context, and reflexivity. Credibility means the appropriate selection of participants that allows for a thorough, relevant collection of data (Pluye, et al., 2011). Context refers to setting and how settings influence data collection (Pluye, et al., 2011). For example, does a for-profit hospital influence nurse executive empowerment differently than a nonprofit hospital? Context must be addressed as data is gathered. Reflexivity, at a minimum, must be discussed, and disclosure of what brought them [researchers] to the question must be provided (Pluye, et al., 2011, p. 3). Qualitative guidelines also encompass the process of data analysis and the setting in which data was gathered (Pluye et al., 2011).
Strategy for Literature Search
The strategy for this integrative review involved an initial search on patient safety, nurse leadership, empowerment, and self-efficacy. Subsequent searches were conducted on empowerment, patient safety, and nurse self-efficacy. Appendix A provides a summary of the literature search, including databases used, search terms applied, and results found.
The search also involved a manual review of reference lists in the articles selected for review. Additional studies were identified from related topics and related searches.
Because the initial literature search did not yield studies on the relationship between nurse executive empowerment, patient safety or self-efficacy in acute care settings, the search was expanded to include research on these topics that involved frontline nurses and midlevel nurse managers.
Inclusion and exclusion criteria
English-language studies, published in peer-reviewed journals from 1997 to 2014, were included in this review if they addressed
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the empowerment of staff nurses and/or nurse leaders;
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staff nurse perceptions of the effects of nurse managers behavior on the work environment;
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nursing-related issues on empowerment, patient safety, and self-efficacy
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acute care settings.
The choice of the time period is mainly associated with the increasing attention paid to empowerment and its effects on the nursing practice among researchers that marked the late 1990s (Greco et al., 2006). Articles were excluded if
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research did not address empowerment, patient safety, or nurse self-efficacy;
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non-nursing research on empowerment, patient safety, and self-efficacy did not directly apply to nursing or hospital environments;
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research on patient or family self-efficacy did not concern nursing or hospital environments; and
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research involved quality improvement projects.
Editorials were excluded.
Search Outcomes
A final sample of 25 research articles was selected for this integrative literature review. Articles on nurse executives were not found. Below is a brief description of the designs and limitations of the studies selected.
Patient safety
Articles on this topic included one literature review and four self-report survey questionnaires. Limitations included longitudinal study designs in which historical events may have influenced the results, cross-sectional designs that precluded determination of causality, and nonrespondent data not being known (Auer et al., 2014; Laschinger, Finegan, Shamian, & Wilk, 2001).
Nurse empowerment
Articles on this topic included a meta-analysis, an integrative review, a systematic review, a mixed research design study, a qualitative study, and 10 studies that used self-report survey questionnaires. Some of the limitations of these studies included heterogeneity, homogeneity, restricted geographic area, cross-sectional designs that precluded statements of cause and effect, and mixed population of acute care providers; these limitations constrain or preclude generalization of the studies findings (Kuokkanan & Katajisto, 2003; Koukkanen, Leino-Kilpi, & Katajisto, 2003; Laschinger, Almost, & Tuer-Hodes, 2003; Laschinger, Finegan, & Wilk, 2011; Morrison, Jones, & Fuller, 1997). Between-study variation in conceptualization and measures presents methodological issues that limit the validity and generalizability of the studies findings (Lee & Cummings, 2008).
Nurse self-efficacy
Articles on this topic included a meta-analysis, a qualitative study, and three self-report survey questionnaires. Limitations included a 15-month lag that made it difficult to determine whether historic events may have influenced the data (LeBlanc, Schaufeli, Llorens, & Nap, 2010). Small sample sizes and homogeneity (i.e., restriction to a single nursing specialty) constrained generalization of study findings and conclusions (Gloudemans, Schalk, & Reynart, 2013). The meta-analysis had a large number of subjects, but the researchers conceded that measurement errors and lack of reliability testing for measurement tools are not uncommon (Franklin & Lee, 2014).
Review of the Literature
Nurse Empowerment
The literature search revealed a scarcity of information specific to understanding how nurse executives experience and perceive empowerment in their role in the hospital setting. However, Laschinger offers extensive research (Laschinger, Finegan & Shamian, 2001; Laschinger, Finegan, Shamian, & Wilk, 2001; Laschinger, 1996; Laschinger & Havens, 1996) on the phenomenon of empowerment of nursing staff and on the unit leaders ability to promote an empowering work environment. Laschinger has used Kanters (1977) organizational theory as a foundation for clarifying the ways in which empowerment is understood and maintained by nursing staff as well as how empowerment is used effectively by nursing leaders (Laschinger, Purdy, & Almost, 2007; Laschinger, Sabiston, & Kutszcher, 1997). This integrative review includes the analysis of four articles that discussed the role of the clinical nurse managers (also known as midlevel managers), in their role as leaders in transforming work environments. Two additional research articles are included as well, because the research involved nurse managers and empowerment.
It was found that frontline nurses perceived effective leadership on the unit level as a source of empowerment for staff (Laschinger, Finegan, & Wilk, 2011; Laschinger, Wong, McMahon, & Kaufman, 1999). For nurse managers at work in their clinical units, being visible and accessible was seen as important for both staff and patients. Unit-level managers who provided resources and demonstrated support by being present on the unit while listening and addressing concerns voiced by frontline staff helped to create a supportive work environment. In addition, the data did show that supportive work environments promote better patient care with improved outcomes (Laschinger, Finegan, and Wilk, 2011; Laschinger, Wong, McMahon, & Kaufman, 1999). Also, in comparison with nurse managers who did not feel empowered, nurse managers who felt empowered had lower burnout rates and had higher job satisfaction (Laschinger, Finegan, & Wilk, 2009; Laschinger, Wong, McMahon, & Kaufman, 1999).
Perceptions of empowerment and organizational support predicted nurse managers job satisfaction (Patrick & Laschinger, 2006; Lee & Cummings, 2008). Job satisfactionthe extent to which a persons hopes, desires, and expectations about their employment are fulfilledis often used to help measure empowerment (Coomber & Barriball, 2006). Lee and Cummings (2008) found the theme of organizational support from nurse executives within the institution was a significant contributing factor to frontline managers perceptions of empowerment. In addition, empowerment of leaders at the unit level had a positive association with perceived job satisfaction of frontline staff as well (Lee & Cummings, 2008; Morrison, Jones, & Fuller, 1997). Although empowerment of unit leaders was shown to improve work satisfaction for frontline nurses as well, it does not discuss the nurse executive leaders to whom nurse managers report to. However, recognition of the importance of nursing leadership and the impact nurse leaders have on staff appears to be important at all levels within the organization.
Nurse executive support is consistent with the organizational theory described by Kanter (1977), an expert in the field of organizational behavior. Organizational empowerment discusses leadership support and employees job satisfaction is closely associated. Lee and Cummings (2008) concluded that increased job satisfaction was perceived when midlevel managers were supported by nurse executives. Midlevel managers indicated support that allowed their involvement in decision making was important and increased their sense of empowerment. In addition, increased job satisfaction correlated with higher recruitment and retention rates of midlevel managers.
Research that focused on the concept of empowerment and elements that contribute to empowerment in nursing was discussed in three papers (Kokanee & Katajisto, 2003; Kuokkanen, Leino-Kilpi, & Katajisto, 2003; Rao, 2012). Empowerment is often referred to when describing nurses who are able to deliver effective patient care (Rao, 2012). The literature indicates that empowerment is an evolving process of interactions among individuals, organizational, and sociocultural factors (Rao, 2012). A perceived sense of frontline staff nurses empowerment identified improved nursing practice that leads to improved patient care (Kuokkanen & Katajisto, 2003; Kuokkanen, Leino-Kilpi, & Katajisto, 2003; Rao, 2012).
Work-related empowerment components such as job satisfaction, self-esteem, career awareness, the availability of training that facilitates higher learning (i.e., medical/surgical nurse completes critical care training), employment status (i.e., benefitted position verses non-benefitted position), and self-perceived commitment to their nursing role are commonly identified as important to nurses perceptions of empowerment (Koukkanen & Katajisto, 2003; Kuokkanen, Leino-Kilpi, & Katajisto, 2003). These researchers also identified factors that appear to impede empowermentfor example, dictatorial leadership and lack of access to essential information. Overall, the teams of investigators agreed that empowerment is a useful concept that can add to our understanding of professional growth and development in nursing (Koukkanen & Katajisto, 2003; Kuokkanen, Leino-Kilpi, & Katajisto, 2003; Rao, 2012).
Job satisfaction is not only a consideration for mid level management but can contribute to staff engagement and staff empowerment which are important considerations in health care studies today (Johnson, 2009). Three articles discussed job satisfaction and staff engagement that increase staffs perceptions of empowerment. Job dissatisfaction can contribute to staff disengaging in their work environment because they are not happy with the environment; in addition they are often absent from work and are not empowered to contribute to safe, high-quality patient care (Johnson, 2009; Zangaro & Soeken, 2007). Inpatient work environments, with increasing workloads that take away from patient care are stressful (Zangaro & Soeken, 2007). Creating a work culture in which nurse executives promote nurse-physician collaboration and decrease job stress while nursing autonomy is encouraged, ensures the delivery of safe, high-quality patient care, high patient satisfaction rates, positive patient outcomes, and staff who are engaged and want to come to work is crucial for patient care (Johnson, 2009; Zangaro & Seen, 2007).
Nurses who are engaged in their work are able to voice their concerns when a process is not working. For example, Laschinger, Almost, and Tuer-Hodes (2003) found that nurses in magnet hospitals tended to communicate freely and report medical errors or any cases that could enhance the delivery of care. The researchers stressed that the nurses working at magnet hospitals enjoyed a considerable degree of autonomy, which was found to contribute to voicing various issues and concerns (Laschinger et al., 2003). These nurses also appear to be more satisfied with their work, and this greater satisfaction is associated with fewer instances of reported burnout (Halbesleben, Wakefield, Wakefield, &
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