The ability to monitor patient safety has become an important parameter to ascertain the quality of care delivered in health care organizations. Effective communication skills underpin well-executed team work. Communication failures, including the inability to exhibit assertive communication skills, are the leading cause of inadvertent harm to patients (Okuyama, Wagner, & Bijnen, 2014).
Empowering employees within an organization was described as a key to responding creatively to any challenges within the job (Orgambídez-Ramos & Borrego-Alés, 2014). Kanter (2008) developed a theory of structural empowerment in organizations, which postulates that employees can attain structured power through four components in the work setting: access to (a) opportunity, (b) information, (c) support, and (d) resources. Formal and informal power are two ways of accessing these elements of structural empowerment by increasing the employees' bonds to the organization and by enabling them to execute jobs that are of high visibility and of importance to the organization's priorities.
Kanter's empowerment theory was used extensively to examine the relationships between nurses' perceived structural empowerment and other important nursing performance, and social and work-related outcomes. For example, statistically significant relationships were reported between nurses' perceived structural empowerment and high levels of organizational commitment (Laschinger, Finegan, Shamian, & Wilk, 2001) and job satisfaction (Manojlovich, 2005). It was also found to be statistically significant and negatively related to exposure to workforce bullying (Laschinger, Grau, Finegan, & Wilk, 2010).
Speaking up was defined in different ways in the literature, although all definitions appeared to have focused on the underlying communication attitude. For example, speaking up was defined by Flin, O'Connor, and Crichton (2008) as “standing up for yourself, in such a way as not to disrespect the other's person opinion” (p. 81). It was also defined as an individual using his or her voice to convey to someone in a higher hierarchy level specific information that may lead to a difference to patient safety (Sayre, McNeese-Smith, Leach, & Phillips, 2012). On the other hand, aggressiveness involves expressing one's views without considering others (Sims, 2017). Both speaking up and assertiveness are often used interchangeably in the literature.
Speaking up is a vital prerequisite for effective communication to ensure safe delivery of patient care within the health care system. Speaking up requires a high level of moral courage from the nurses (Numminen, Repo, & Leino-Kilpi, 2017). It reinforces the feeling of self and job satisfaction, helps to develop professional and patient advocate identity, and increases belonging to the organization (O'Mara, McDonald, Gillespie, Brown, & Miles, 2014). Lack of speaking up ability, on the other hand, is likely to cause moral distress to individual nurses who feel powerless and unable to exert their assertive communication. Moral distress is reported to be associated with burn-out, fatigue, and eventually leaving the profession (Hamilton Houghtaling, 2012; Wilson, Goettemoeller, Bevan, & McCord, 2013).
Much of the research that examined assertiveness among newly graduated nurses has focused on organizational and work-related factors. For example, previous research suggests that newly graduated nurses perceive the transition into their new professional role as highly stressful (Gerrish, 2000; Higgins, Spencer, & Kane, 2010; Parker, Giles, Lantry, & McMillan, 2014). Therefore, newly graduated nurses may often be seen as vulnerable health care professionals who face difficulties in clearly highlighting their concerns on unsafe practice to other nurses and health care professionals. Duchscher (2009) used the transition shock theory to analyze newly graduated nurses' experience of moving from being nursing students to the new role of fully practicing nurses, and he reported that newly graduated nurses felt stressed, anxious, and insecure. Clark and Holmes (2007), Gerrish (2000), and Maben, Latter, and Clark (2007) argued that this lack of confidence is short-lived and that after gaining experience in practice, newly graduated nurses experience an increase in confidence and knowledge. However, other research suggests that although such a short-lived experience of low confidence may be more pertinent to the immediate time of mobilization, subsequent adjustment stages may also be associated with challenging situations, albeit in different contexts, including how to exhibit assertive communication behaviors when necessary. For example, Mooney (2007) conducted 10 semi-structured interviews with newly qualified Irish nurses 10 months after they graduated. He reported that although the nurses experienced improved levels of confidence and assertiveness as they felt acknowledged and had increased status, they often faced the dilemma of how to translate such assertiveness into practice.
It has been suggested that the theory–practice gap was a common disincentive for raising concerns against poor practice (Mooney, 2007). What was considered safe practice in the university may often be at variance with practice in actual clinical settings. This may also be common experience in other health education disciplines. The United Kingdom Nursing & Midwifery Council (2013) emphasized that speaking up on behalf of people and patients receiving care is vital, whereas doing nothing and failing to report concern is unacceptable and may result in fitness-to-practice investigations. However, these requirements do not seem to consider the context of newly graduated nurses by imposing unrealistic expectations and asking them to speak up against unsafe practice when they may not be fully equipped to do so. Maben et al. (2007) reported that newly graduated nurses sometimes face a defensive response from the new work environment. This undermines their inquisitive communication approach and may help to engage them in unsafe clinical practice (Feng & Tsai, 2012). Thus, newly graduated nurses may face a degree of emotional outbursts regarding skill transfer from university to practice settings, and they often struggle to exhibit confidence in translating speaking up behavior in a potentially defensive working culture (Higgins et al., 2010). Moreover, some work cultures do not endorse high-caliber attitudes, such as questioning the practice of others, where more senior staff or preceptors may have skeptical views of such an idealistic approach within the clinical setting. Therefore, newly graduated nurses may inevitably pick up on such attitudes and follow suit (Parker et al., 2014). Findings from previous research suggest that nursing students do conform to the staff and mentors' expectations to fit into placement cultures (Andrew & Mansour, 2014; Levett-Jones & Lathlean, 2009) and sometimes remain passive spectators when faced with unsafe practice (Bickhoff, Sinclair, & Levett-Jones, 2007). However, little evidence exists to support or to refute this assumption in the context of newly graduated nurses conforming to their senior peers. The experience of newly graduated nurses' transition from the university setting into their full mature professional role, as well as the perceived support from other colleagues and the work setting, appear to be crucial factors for shaping newly graduated nurses' assertive behaviors, but there is little empirical evidence that used Kanter's organizational empowerment theory in assessing British newly graduate nurses' self-reported empowerment and its association with their speaking up behaviors against unsafe practices. The aim of this study is to examine British newly graduated nurses' experience of their perceived organizational empowerment and willingness to challenge unsafe practices.
A cross-sectional survey, with both quantitative and qualitative elements, was used in this study. This article reports on the findings from the quantitative part. The principal investigator (M.M.) has previously used this approach successfully (Andrew & Mansour, 2014).
Sampling frame of nurses who met the eligibility criteria and from which the final sample of the participant was drawn consisted of 110 newly graduated nurses across the four hospitals. The questionnaire was distributed to a convenience sample of 84 newly graduated nurses working at four acute hospitals in eastern England. The four hospitals were selected because they were within geographical proximity to each other and to the university where the research team was based. The study adopted the United Kingdom's Department of Health (2010) definition of newly graduated health care professionals, including nurses, as:
A nurse…who is entering employment in England for the first time following professional registration with the Nursing & Midwifery Council or Health and Care Professionals Council. It includes those who are recently graduated students, those returning to practice, those entering a new part of the register e.g.…overseas-prepared practitioners who have satisfied the requirements of, and are registered with, their regulatory body.
Nurses were eligible to participate in this study if they had graduated from a higher education institution in the United Kingdom, had actual working experience of 18 months or less, and had been enrolled in a hospital-based preceptorship program.
The quantitative part of the survey consisted of a Conditions of Work Effectiveness Questionnaire (CWEQ-II), and four hypothetical scenarios on attitudes to speaking up. The CWEQ-II was developed and validated by Laschinger et al. (2001) and is designed to examine perceived structural empowerment within an organization. It has been used extensively in international nursing research (Bish, Kenny, & Nay, 2014; Greco, Laschinger, & Wong, 2006; Laschinger, 2008). The questionnaire consists of 19 items and a 5-point semantic differential scale (1 = none, 5 = a lot) that measures the newly graduated nurses' perceptions of Kanter's four components of structural empowerment: access to opportunity, information, support, and resources. There is an additional three-item, subscale describing job activities, that measure perceived formal power, and a four-item organizational relationship sub-scale which measures perceived informal power. Higher scores represent stronger perceptions of empowerment at work. The second part of the quantitative survey consisted of four speaking-up hypothetical scenarios.
The speaking up hypothetical scenarios were developed and used previously in the context of undergraduate nursing students (Andrew & Mansour, 2014), and they are used in this study to assess the participants' self-reported willingness to challenge perceived unsafe practices. The scale consists of four hypothetical scenarios examining challenging, but common, clinical situations that nurses routinely confront in the clinical setting. This includes challenging a nursing colleague when performing unsafe patient manual handing procedure and providing nursing care, staff who has just administered an intravenous medication to the incorrect patient and was disinclined to report it, disclosing medication administration errors to a patient, and stopping a medical doctor who infringed on the privacy of a patient while the patient was having personal care. For each scenario, the participants were asked to indicate on a 5-point Likert scale whether they would take an action (which is suggested for each scenario) to safeguard the patient's welfare. The possible scores ranged from 1 to 5, and higher scores indicate a greater propensity for speaking up. The four scenarios were originally developed by two academic staff members and were subsequently revised and approved by four other experienced academic and hospital staff to ensure the face and content validity.
To recruit the participants, a research assistant (RA) attended each ward at the selected hospital sites and handed over the questionnaires to all newly graduated nurses working on the ward during that shift. Copies were also left for other newly graduated nurses working in the same ward but were not present on that shift. The nurses were asked to complete the questionnaire and to either return it to the RA who would come back toward the end of the shift or to return it later to a designated letter box set up in the selected hospitals. The questionnaire was piloted on six newly graduated nurses. The pilot study was conducted to uncover any problems in the readability and understanding of the questions, particularly those related to the hypothetical scenarios where some nurses may not be exposed sufficiently to some of the proposed scenarios. All participants who were involved in the pilot study reported no significant problems in their understanding and completion of the questionnaire, and on average, it took them 8 minutes to answer all the questions. The participants who participated in the piloting stage were excluded from the final study sample. The RA visited the wards again to remind the participants of the study after 6 weeks; this is because newly graduated nurses are usually enrolled in the preceptorship program in the first year of employment, which dictates them to attend training workshop days outside their usual ward setting. Hence, they spend less time in their wards compared with other more experienced nursing staff. Allocating a longer time for them to respond is likely to give them more opportunity to complete the survey, particularly when responding to a delicate topic such as perceived organizational empowerment and personal assertive communication abilities. Data collection lasted from June 2015 to January 2016.
The research was approved by the Faculty Research Ethics Panel at the university where this study took place. The Research and Development Department approvals at each hospital site were also obtained before data collection started. The Participants Information Sheet explained the purpose of the study, the likely risks and benefits, and what the participants had to do if they wished to participate; it also stressed the voluntary nature of participation. Implied consent was sought in this study whereby the participants could withdraw at any time without giving a reason by simply not completing or returning the questionnaires. The recruitment process attempted first to recruit newly graduated nurses by direct contact (directly handing out the questionnaires). The RA had to introduce herself to whoever was in charge in the ward during that shift and then spoke to the potential participants to invite them to participate in the study. The reason for this is to recruit participants directly and avoid approaching ward managers to ask nurses to participate in the study, which may affect the nurses' views when completing the questionnaire. Earlier research, which adopted a similar recruitment strategy, found that such an approach helps more junior nurses to express their views more freely, particularly when discussing sensitive topics such as speaking up against unsafe practices (Mansour, 2011; Taxis & Barber, 2003).
The participant responses were coded and entered into SPSS® software version 21 for data analysis. The demographic data were analyzed using summary statistics, including frequencies, mean, and standard deviations. Participants' responses on the CWEQ-II six subscales and speaking up scale items were summed and averaged to provide a score for each subscale. Scatterplot display of the relationships between the correlated variables confirmed a nonlinear, monotonic relationship, which violates assumption for the use of parametric test (i.e., Pearson correlation coefficient). Therefore, the Spearman correlation coefficient (rho) was used to explore any relationships between the participants' responses on both the structural empowerment subscales and the speaking up scale.
In total, 51 questionnaires were completed and returned by the participants, for a response rate of 61%. Table 1 indicates the demographic data of the participants. This sample size exceeded the minimum of 33 required for a correlation analysis based on Cohen's (1988) statistical method (significance level α = 0.05, 1−β = .80, rho = .47). The most frequently reported clinical work settings for the participating nurses were medical and surgical wards (31.4% and 35%, respectively), with fewer participants working in more specialized clinical areas. This is probably because working in specialized clinical areas, such as the intensive care unit and high dependency unit, typically requires nurses to have prior clinical experience before joining such highly specialized and complex work settings (Valentin, Ferdinande, & ESICM Working Group on Quality Improvement, 2011). Three of the four selected hospital campuses had almost comparable participants' response rates (ranging from 27% to 31%). Participants from the fourth hospital campus represented only 10% of the total sample size (38% response rate at this hospital site).
Demographic Profile of Respondents (N = 51)
Table 2 shows the Cronbach's alphas, means, standard deviations, and Spearman rho correlations coefficients for the participants' responses for the CWEQ-II and the speaking up scale. The Cronbach's alpha for the CEWQII was .86, which is consistent with previous measures for the internal consistency of the instrument (Bish et al., 2014; Laschinger et al., 2010). For each CWEQ-II sub-scale, the Cronbach's alpha measures ranged from .64 to .86. The newly graduated nurses reported an overall average workplace empowerment score of 13.8 (SD = 0.52), which is classified as a moderate level of empowerment (Laschinger et al., 2010) and is similar to other previously reported work on empowerment levels for newly graduated nurses (Bushell, 2013; Laschinger et al., 2010). In the current study, access to opportunity was rated the highest (M = 4.13, SD = 0.71), and access to resources rated the lowest (M = 2.9, SD = 0.73). Informal power was rated more than the formal power (M = 3.7, SD = 0.75). Moreover, the participants reported a high score on the speaking up scale (M = 4.47, SD = 0.76), which suggests a high degree of willingness to intervene and challenge the perceived unsafe clinical practices in the given hypothetical scenarios.
Cronbach's Alphas, Means, Standard Deviations, and Spearman rho Correlation Coefficients
The correlation values that are generated between the total scores and subscales of the major study variables are indicated in Table 2. They reveal a statistically significant correlation between the participants overall perceived work empowerment and their reported degree of speaking up and ability to challenge unsafe practice (r = .472, p ⩽.01). Opportunity, access to information, and informal power subscales were all found to have statistically significant correlations with the speaking up attitudes scale, with the informal power subscale having the strongest associations (r = .480, p ⩽.01).
Few studies have examined the empowerment of newly graduated nurses in a work setting and the effect of this on the dynamics of the workforce, and to our knowledge, the current study is the first to use the CWQ-II among newly graduated nurses in the United Kingdom. The study reported a moderate level of work empowerment for newly graduated nurses. This can be understood in the context of the inexperience of the participating nurses and their underdeveloped confidence, assertiveness, and professional diplomacy (Sahay, Hutchinson, & East, 2015). The participants' highest ranking of structural empowerment components was access to opportunity, which underscores their positive attitudes toward their potential for professional growth and movement within the organization, as well as the opportunity to increase knowledge and skills. Kanter (2008) has suggested that an important motivational factor in the work environment is one that fosters the prospect of increasing knowledge and skills among its employees. However, this only applies if complemented by an appropriate person–job fit. More specifically, there is a substantial congruence between the nurses' expectations and their working conditions, where they experience reasonable workloads, they are being treated fairly and rewarded for their contributions, and their values are congruent with organizational values (Greco et al., 2006). In contrast, formal power was rated lowest by the participants and this also was not surprising in the light of their junior status and their reliance on other colleagues to acquire the necessary experience at the start of their career.
The findings also suggest statistically significant correlations between the participant speaking up attitudes and their reported access to opportunity, access to information, and informal power (which has the strongest associations among all correlated components). Previous empirical research has demonstrated how nurses' work empowerment affects their intention to stay in the profession (Nedd, 2006), enhances professional practice behavior (Laschinger et al., 2001) and work engagement, and leads to a sense of satisfaction (Laschinger, Wilk, Cho, & Greco, 2009). The current research study confirms that work empowerment may also make an important contribution toward developing and nurturing newly graduated nurses' communication skills and speaking up behaviors. Interestingly, the participants reported a high level of confidence in challenging unsafe practices in the given scenarios, in contrast with much of the evidence from the literature, which suggests that newly graduated nurses feel hesitant in exhibiting their assertive behavior (Law & Chan, 2015; Schwappach & Gehring, 2014); such differences may be attributed to the fact that research samples in other studies included nurses with various levels of experience (i.e., nursing students, newly graduated nurses, senior nurses and nurse managers). Nurses may have developed various levels of confidence to speak up as they develop more clinical and managerial experience (Schwappach & Gehring, 2014). Other studies recruited only newly graduated nurses who are purposively chosen in the research sample as they were identified as those who are committed to performing excellent nursing activities and are likely to have higher moral courage compared with average, perhaps less enthusiastic newly graduated nurses, and therefore may have expressed a stronger driver for expressing speaking up behaviors (Law & Chan, 2015).
It was reported that newly graduated nurses may feel insecure in their initial employment and that they tend to develop social connections and establish comfortable communication channels with other health care professionals to fit better into the new team (Levett-Jones & Lathlean, 2009). Findings from this study suggest that such a strategy, which Kanter (2008) refered to as informal power, may have an influential role in developing and consolidating newly graduated nurses' assertive communication behaviors. Once they feel settled, acknowledged, and more confident with their knowledge and skills, they become capable of forming healthy working relationships with their peers, and this serves as a platform for practicing more assertive communication behaviors, at least with their own trusted peers with whom they feel more comfortable about challenging without fear of retribution.
The convenience sample used in this research meant that caution must be exercised when applying the results to other contexts. Also, this research examined the ability of newly graduated nurses to exercise speaking up behavior in response to hypothetical, unsafe practice events. More research is needed to focus on the operational skills nurses may need to acquire to improve their self-confidence in challenging unsafe practices.
The findings from this study demonstrate links between newly graduated nurses' perceived structural empowerment in their work setting and their speaking up behaviors based on four hypothetical scenarios of unsafe practices. The perceived opportunity for professional growth and access to the necessary information that helps nurses to discharge their duties in a safe manner were found to be important indicators for newly graduated nurses' speaking up behaviors. To settle into their new working environment, newly graduated nurses needs guidance, support, and acknowledgment from their peers. In addition, a working environment, which is dominated by hostile, unsupportive, and disruptive behaviors is likely to discourage the building of self-confidence, with subsequent, potentially lasting damage to newly graduated nurses' sense of confidence and empowerment. Nurse managers and staff development nurses should pursue strategies that nurture self-confidence building among newly graduated nurses, but also create a supportive working culture that encourages speaking up behaviors among junior, but also senior nurses and other health care professionals. For nurse educators and nurse managers, strategies may include the introduction of key performance indicators where supporting the newly graduated nurses becomes a key professional development skill for the more senior nurses, and where nurses must submit evidence of having supported and empowered newly graduated nurses during the past year, and setting relevant, mutually-agreed objectives in the next year. This is likely to ensure a more structured approach for supporting and empowering newly graduated nurses, but also developing a peerfriendly approach for practicing assertive communication skills among newly graduated nurses. Further research is needed to better understand the contextual factors that drive such high assertiveness skills, given the evidence from the literature that suggests otherwise.
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Demographic Profile of Respondents (N = 51)
| 20 to 25||29||56.86|
| 26 to 30||10||19.6|
| 31 to 35||2||3.92|
| 36 to 40||3||5.88|
|Length of experience (months)|
| 0 to 6||23||45.14|
| 7 to 12||16||31.37|
| 12 to 18||9||17.65|
|Type of clinical work setting|
| Medical ward||16||31.4|
| Surgical ward||18||35.3|
| High dependency unit||2||3.9|
| Coronary care unit||1||1.96|
| Accident & emergency||1||1.96|
| Hospital A||16||31.4|
| Hospital B||16||31.4|
| Hospital C||14||27.5|
| Hospital D||5||9.8|
Cronbach's Alphas, Means, Standard Deviations, and Spearman rho Correlation Coefficients
|Variables and Subscales||α||Mean||SD||1||2||3||4||5||6||7||8|
|1. Average total empowerment||.86||13.80||0.52||-|
|3. Access to information||.79||3.40||0.76||.575**|
|4. Access to support||.82||3.35||0.91||.815**|
|5. Access to resources||.76||2.90||0.73||.454**|
|6. Formal power||.78||2.93||0.82||.689**|
|7. Informal power||.75||3.70||0.75||.720**|
|8. Speaking up attitudes||.76||4.47||0.69||.472**||.326*||.395**||.215||.044||.279||.480**||–|