Running head: GRADUATE NURSE EMPOWERMENT WITHIN ROLE SOCIALIZATION
Graduate Nurse Empowerment within Role Socialization: A Concept Analysis
Rachel Drosselmeyer, RN, BSN, Kathleen Power, RN, BSN, and Heather Sloan, RN, BSN
Washburn University
Theoretical Foundations for Advanced Nursing Practice
NU500
Dr. Maryellen McBride and Dr. Marilyn Masterson
December 8, 2010
1
GRADUATE NURSE EMPOWERMENT WITHIN ROLE SOCIALIZATION
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Concept Selection
The concept that was selected examines nurse empowerment within the context of role
socialization. Marlene Kramer’s book Reality Shock, published in 1974 defines “reality shock”
as the phenomenon of school-bred values conflicting with work values which produces a shocklike reaction (Kramer, 1974, p.4). Kramer’s book adequately describes the transition new
graduates experience today. The authors’ personal experience created a strong desire to
investigate the concept. An extensive review of literature reveals this concept perpetuates in the
nursing field today. The current nursing shortage is expected to reach more than 1 million by the
year 2020 (American Association of Colleges of Nursing website, 2010). As many as 61% of
nurses change their place of employment or choose to leave the nursing profession within their
first year of practice (Boychuk & Duchscher, 2009, p. 1104). The growing shortage of nurses
coupled with the high turnover rate makes this concept worth investigating.
Purpose
The purpose of this analysis is to clarify the meaning of empowerment within the context
of nurse role socialization. Empowerment is an abstract concept that has been used in many
disciplines which have created different meanings derived from a variety of perspectives. A
thorough understanding of the term is crucial to attaining empowerment in practice (McCarthy &
Freeman, 2008; Kuokkanen & Leino-Kilpi, 2000; Gibson, 1991). For the nursing profession to
thrive when a shortage is projected to increase, it is important to clarify the concept of
empowerment and discover how it benefits a new nurse’s socialization.
GRADUATE NURSE EMPOWERMENT WITHIN ROLE SOCIALIZATION
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Concept Definition
Literature Definition
The World English Dictionary (2010) describes the term empowerment as: “(1) The
giving or delegation of power or authority; authorization, (2) the giving of an ability; enablement
or permission and (3) (in South Africa) a policy of providing special opportunities in
employment, training, etc for Black people and others disadvantaged under apartheid.”
Empowerment as defined by Taber's Cyclopedic Medical Dictionary (2009): “(1) Investing
power in another person or group by sharing leadership roles, or helping others to engage fully in
a process and (2) Participating actively and autonomously in policies or events that affect one’s
health or well-being.” Empowerment as defined by Churchill Livingstone's Dictionary of
Nursing (2006): “The enabling process by which individuals gain power and control over
decisions that affect their lives. For example, it may occur when people with a learning disability
acquire the skills needed to live independently.” Gibson’s definition of empowerment for
nursing (1991) is: “A social process of recognizing, promoting, and enhancing people’s abilities
to meet their own needs, solve their own problems, and mobilize the necessary resources in order
to feel in control of their own lives” (p. 359).
Operational Definition
For the purpose of this analysis, empowerment can be defined as an enabling process by
which nurses gain autonomy, confidence, and self-esteem in order to feel in control in practice.
This definition serves to frame the concept the authors will discuss in the following analysis.
GRADUATE NURSE EMPOWERMENT WITHIN ROLE SOCIALIZATION
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Review of Literature
Introduction
The topic of nurse empowerment during role socialization was researched on September
9th, October 23rd, October 27th, and November 14, 2010 using CINHAL, ProQuest, and SAGE
databases. A variety of Boolean terms were used including: empowerment, role socialization,
neophyte nurse, concept analysis, and nurs*. Of the articles reviewed, six were nursing research
studies specific to nurse empowerment and role socialization. These studies were chosen to be
included in this review of literature. See Appendix A for a detailed chart reflecting this
investigation.
Body
Faulkner and Laschinger (2008) conducted a secondary analysis from a study that
included 500 staff nurses. The study used a predictive, non-experimental survey to examine
relationships between structural and psychological empowerment. The purpose of this study was
to “explore the effects of structural and psychological empowerment on perceived respect in
hospital nurses” (Faulkner & Laschinger, 2008, p. 215). Data was collected via use of three
instruments including Conditions of Work Effectiveness Questionnaire-II, Psychological
Empowerment Questionnaire, modified Esteem Subscale of the Effort-Reward Imbalance
Questionnaire (Faulkner & Laschinger, 2008, p.217-218). A total empowerment score was
created via the sum of the subscales. Nurses in this study reported moderate structural and
psychological empowerment. Opportunity was identified as the most empowering structure.
Minimal access to formal power structures was identified by nurses. A sense of meaning and
competence was reported. New nurses did not feel they had a significant impact on the
organization. Collectively, the findings support that employees who have access to empowering
GRADUATE NURSE EMPOWERMENT WITHIN ROLE SOCIALIZATION
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structures also have positive attitudes toward work and a sense of personal empowerment.
Limitations included bias introduction through the use of self-reported questionnaires and the
cross-sectional design which limits claims of cause and effect (Faulkner & Laschinger, 2008, p.
219-220). The study helps the analysis of empowerment by describing attributes of the concept.
Laschinger, Leiter, Day, and Gilin (2009) conducted a quantitative study with a sample of
612 Canadian staff nurses. The aim was to “examine the influence of empowering work
conditions and workplace incivility on nurses’ experiences of burnout and important nurse
retention factors identified in the literature” (Laschinger, Leiter, Day, & Gilin, 2009, p. 303).
Data was collected through a short form of the Conditions for Work Effectiveness Questionnaire.
This tool measures employee access to work empowerment structures per Kanter’s theory.
Emotional Exhaustion and Cynicism were measured by the Burnout Inventory- General Survey
(Laschinger et al., 2009, p. 305). Job satisfaction was measured by having participants rate their
level of satisfaction in five key areas. Two items from the Affective Commitment Scale were
used to measure organizational commitment and three items from the Turnover Intentions scale
were used to measure the individual’s intention to leave his or her current position (Laschinger et
al., 2009, p. 306). The study found that empowering practice environments with low levels of
incivility and burnout were significant predictors of a nurse’s job satisfaction, intent to leave the
workplace, and organizational commitment. In addition, empowerment and incivility
significantly impacted nurses’ experiences of burnout, suggesting management should focus on
empowerment to increase job satisfaction and quality care. The study identified a significant
relationship between structural empowerment and nurse turnover (Laschinger et al., 2009, p.
308-309). Limitations include the cross-sectional nature that prevents strong claims of causal
effects. The study suggests that it would be valuable to replicate the investigation with a larger
GRADUATE NURSE EMPOWERMENT WITHIN ROLE SOCIALIZATION
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sample of nurses and conduct a longitudinal study to examine changes over time (Laschinger et
al., 2009, p. 309). This study assists the analysis of empowerment by discussing consequences
of empowerment.
Duchscher (2009) conducted four qualitative research studies that ranged from six to
eighteen months with four to fifteen nurses. The goal was to “provide a theoretical framework of
the initial role transition for newly graduated nurses” (Duchscher, 2009, p. 1103). Data was
collected through a pre-interview questionnaire, monthly journal entries and structured
interviews submitted by the subjects at various periods (Boychuk Duchscher, 2009, p. 11041105). The author identified emotional, physical, sociocultural, developmental and intellectual
aspects that either hinder or help professional role development. Limitations identified included
all four studies were based on students that graduated from the same nursing program.
Additionally, the terms “seasoned” and “newly graduated” were not defined. This article was
beneficial to the concept analysis because it took into consideration many aspects that influence
the new graduate’s role socialization.
Dyess and Sherman (2009) conducted a qualitative research study on 81 participants in
the Novice Nurse Leadership Institute (NNLI), a community-based transition program in Florida.
The aim was to identify the learning needs of newly graduated nurses and offer
recommendations for continuing education and orientation (Dyess & Sherman, 2009, p. 404).
Data was collected through 20 educational sessions where members participated in discussion
and answer sessions. Pre- and post-program focus groups using hermeneutic analysis along with
a literature review focusing on the learning needs of new nursing graduates were used (Dyess &
Sherman, 2009, p. 405. Six key areas were identified by participants as barriers to socialization
into the workplace and recommendations to remedy these obstacles were given by the authors
GRADUATE NURSE EMPOWERMENT WITHIN ROLE SOCIALIZATION
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based on their research (Dyess & Sherman, 2009, p. 406-409). While recommendations are
made from each key area identified by the authors as needing improvement, some of the
recommendations are vague. Despite this, these recommendations assist with empowering
graduates by providing the support they need to make an easier transition into their professional
role.
Andersson and Edberg (2007) conducted a qualitative study in Sweden examining the
transition new registered nurses experience during their first year of practice (p. 187). The
sample consisted of eight registered nurses employed approximately 12 months in a hospital. All
study participants had a mentor from one to five weeks (Andersson & Edberg, 2007, p. 187).
The study was conducted through a series of eight interviews that were narrative and began with
the question, “Could you please tell me about your present [work] situation” (Andersson &
Edberg, 2007, p. 187). Participants’ responses were scrutinized for similarities in meaning and
word choice. The study found “rookie” nurses need “to be accepted by colleagues” and feel they
are important, contributing members of the healthcare team (Andersson & Edberg, 2007, p. 188).
Thus, in order to maintain peer approval and respect, new nurse graduates may over-estimate
their abilities and often avoid asking for help (Andersson & Edberg, 2007, p. 188). Instead of
feeling closer to the other nurses, new graduates often feel very isolated and alone (Andersson &
Edberg, 2007, p. 188). After working as a nurse for a year, new nurses start to develop
confidence and are able to convey this to their patients and peers. The study findings correspond
to Benner’s Novice to Expert Model by examining the transition nurses experience after
graduating nursing school and the task oriented manner in which novice nurses tend to practice
(Andersson & Edberg, 2007, p. 190). While Andersson's study makes an interesting point
regarding the large impact nurses’ peers have on graduates’ performance, the sample size seems
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small. A larger sample would increase the study’s validity. In addition, the study question is
broad and the follow-up questions are unclear. Novice nurses become advanced beginners when
they are able to prioritize tasks and use their time more effectively which occurs approximately a
year or so after beginning practice (Andersson & Edberg, 2007, p. 190).
Etheridge (1999) conducted a descriptive, longitudinal, phenomenological study in
Michigan. Three semi-structured interviews were conducted on two graduating classes of
registered female nurses, who began working in a hospital (Etheridge, 1999, p. 25). The
interviews were tape-recorded on the following occasions: at the end of nurses’ preceptorship, at
two to three months, and at eight to nine months (Etheridge, 1999, p. 25). The study found
novice nurses have difficulty making clinical decisions and lack self-confidence (Etheridge,
1999, p. 25-26). This is because new nurses lack self-confidence (Etheridge, 1999, p. 25). New
nurses search for “an authority” figure to emulate and “help them to think like a nurse”
(Etheridge, 1999, p. 26). After working for approximately nine months, new nurses “[develop]
the ability to make decisions that are more complex and act on those decisions” (Etheridge,
1999, p. 26). The study found the best way to teach new nurses critical thinking skills was to
increase exposure to various clinical situations and experiences (Etheridge, 1999, p. 28). Varied
experiences increase new nurses’ confidence and self-esteem. Nurse graduates learn best with
hands-on-experience, short peer discussions, and strong colleague support (Etheridge, 1999, p.
28). Limitations include failure to give a number of participants. Thus, the study would increase
its legitimacy by clearly stating the exact sample size. The importance of peer support and
approval builds on the previous study’s findings. New nurse graduates have difficulty making
decisions due to their lack of exposure and experience during nursing school (Etheridge, 1999, p.
27-28).
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Conclusion
From the review of literature six studies have been found that measure empowerment and
explore the different phenomena leading to empowerment. In Faulkner and Laschinger’s 2008
study nurses reported increased structural and psychological empowerment as evidenced by
increased opportunity, meaning, and competence. Laschinger, Leiter, Day, and Gilin’s 2009
study found that empowering practice environments lead to increased job satisfaction,
organizational commitment, decreased intent to leave, and decreased burnout. Duchscher’s 2009
study identified many aspects that provide a theoretical framework for professional socialization.
Dyess and Sherman’s 2009 article distinguished six key areas as barriers to new nurse
socialization and gave recommendations to remedy these obstacles. Andersson & Edberg’s 2007
study found the impact peer approval and support has on increasing graduate confidence and
self-esteem. Etheridge’s 1999 study discusses the manner in which new nurses learn best and
why they have difficulty making decisions. Together these six studies create a consistent picture
of empowerment during role socialization.
Defining Attributes
According to Walker and Avant (1988), defining attributes are “those that are inherent
and essential to the meaning of the concept” (p.39). Defining attributes help differentiate the
concept from other similar or related concepts (Walker & Avant, 1988, p. 39). Two types of
empowerment can be identified within role socialization and include psychological
empowerment and structural/organizational empowerment. As cited by Faulkner and Laschinger
(2008) Kanter (1977) has identified four defining characteristics of psychological empowerment
including: autonomy, competence, finding meaning in one’s work, and believing one has an
GRADUATE NURSE EMPOWERMENT WITHIN ROLE SOCIALIZATION
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impact (p. 215). Faulkner and Laschinger (2008) also cited Kanter’s (1977) five defining
attributes of structural empowerment as: information access, support with access to opportunity,
resources, learning opportunity, and formal and informal power (p. 215). See Appendix B for a
model of empowerment’s defining attributes.
Model Case
The following is a model case that exemplifies the concept of empowerment in relation to
the novice nurse. Chloe, a 25 year old nursing graduate, started working on a medical-surgical
floor in a Wisconsin hospital. Her preceptorship is twelve weeks. She is paired with a preceptor,
Susie, a nurse who is employed on the same shift and floor, has received formal teaching on how
to educate new nurses. Chloe shadows her preceptor Susie for the first week. At the end of each
day, Chloe and Susie attend a peer mentor and mentee discussion group for an hour. The group
discusses various clinical situations and nursing outcomes. She meets with the nursing
supervisor to discuss the pairing of her personality to that of her preceptor. If the new graduate
does not feel comfortable with the pairing, a new preceptor will be arranged. During Chloe’s
second week she attends a skills lab where she must successfully pass 15 skills stations, showing
she is adequately prepared to work on the medical-surgical floor. After a thorough introduction
to the hospital’s electronic medical record system, Chloe is ready to take on her first two
patients. Susie closely follows her during her preceptorship and gives feedback, homework
assignments, and suggestions on how to improve her skills. At the end of her preceptorship, she
feels confident to care for six patients. Chloe feels a sense of respect and camaraderie with the
other nurses. Upon completion, Chloe feels a close bond to the other staff. She feels
comfortable caring for patients, and is able to prioritize her time effectively. See Appendix C for
a detailed table on empowerment approaches for nurses.
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Contrary Case
The following is a contrary case that describes failure to achieve empowerment. Mary, a
23 year old nurse, has just graduated and obtained a job as a night-shift nurse on a post-surgical
unit in a large city hospital. After a general hospital orientation, Mary begins her six week
orientation to the post-surgical unit. No specific nurse is assigned as Mary’s preceptor. Her
preceptor will be assigned each shift based on who is willing to precept. She is given a “checkoff sheet” with various skills she must accomplish independently. Most days, instead of being
guided by her preceptor, both nurses “share the load” of patients they are assigned. Mary often
overhears her coworkers complaining about how “slow” she is at accomplishing tasks which
makes her feel very isolated. She is not given formal introductions to the staff and no one
acknowledges her unless she is needed for something. Additionally, Mary is not given time with
her supervisor to discuss how she feels orientation is progressing. At the end of orientation,
Mary feels she is expected to be proficient on this unit and feels increasingly alone. After
orientation she is given eight patients to care for and feels completely unprepared to be on her
own. After trying to meet many unrealistic expectations, Mary decides to resign from her
position and reevaluate her career as nurse.
Antecedents and Consequences
Antecedents according to Walker and Avant (1988) are “those events or incidents that
must occur prior to the occurrence of the concept” (p.43). Empowerment’s antecedents include:
1.
2.
3.
4.
5.
Motivation
Participation
Commitment
Acceptance of change
Decision making authority
GRADUATE NURSE EMPOWERMENT WITHIN ROLE SOCIALIZATION
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“Consequences are those events or incidents that occur as a result of the occurrence of the
concept” (Walker & Avant, 1988, pg. 43). Empowerment’s consequences include:
1. Job Satisfaction
2. Confidence
3. Professional self-esteem
4. Competence
5. Ability to set and reach goals
6. Problem solving
7. Sense of control over practice
8. Professional Autonomy
9. Decreased intent to leave current position and nursing profession.
10. Organizational commitment
Empirical References
Walker and Avant (1988) call for “identification of empirical referents” (p. 43). Due to
the abstract nature of the concept of empowerment, multiple researchers do not identify specific
empirical indicators during concept analysis (McCarthy & Freeman, 2008). The authors of this
concept analysis identified a possible tool to test competency which is a consequence of
empowerment. This could assist in developing a tool that may identify empirical referents in the
future. The Six Dimension Scale (6D Scale) of Nursing Performance has been widely used
(Meretoja, 2004). The scale consists of 52 items divided into six sub-categories (Meretoja,
2004). A recent study compared the 6D scale to the Nurse Competence Scale (NCS) developed
from Benner’s Novice to Expert model. The Nurse Competence Scale consists of 73 items, with
seven categories (Meretoja, 2004). Findings show the NCS “is useful in the self-assessment of
[new nurse] competence” (Meretoja, 2004). More data is needed to prove greater reliability and
validity of the Nurse Competence Scale. The NCS is also largely subjective in nature, relying
exclusively on new nurse graduates perception of competency (Meretoja, 2004).
GRADUATE NURSE EMPOWERMENT WITHIN ROLE SOCIALIZATION
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Conclusion
Empowerment can be defined as a process that new nurses must experience in order to
thrive in their professional role. After a review of literature, it is apparent Kramer’s notion of
reality shock is still relevant to nursing researchers today. Studies have shown the same aspects
that contribute to increased feelings of empowerment also facilitate role socialization with
graduate nurses. The body of knowledge on this specific topic is limited and further exploration
could assist in retaining nurses in the future. While empowerment remains an abstract concept,
this analysis assists with defining the term in an applicable manner.
GRADUATE NURSE EMPOWERMENT WITHIN ROLE SOCIALIZATION
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Appendix A
Review of Literature Search Strategies and Results
Search Term
Empowerment AND
nurs* (document text
searched)
Empowerment AND
Nurs* AND Role
Socialization
(document text
searched)
Empowerment AND
Role Socialization
(document text
searched)
Benner AND Novice
Nurse
Benner AND
Education AND
Student
Patricia Benner AND
Nursing (full text)
Patricia Benner AND
nurs* AND Education
(full text)
Patricia Benner AND
Model AND nurs*
Patricia Benner AND
Theory AND Student
Nurse (full text)
Socialization AND
Benner (full text)
Benner AND Student
Benner AND Student
AND Model
Benner AND Student
AND Novice AND
ROLE
Benner AND
Neophyte AND
Novice AND Expert
CINHAL
12,767 results
49 Results
ProQuest
3,420 Results
SAGE
8,124 Results
0 Results
17 Results
39 Results
36 Results
(4 studies used for this
concept analysis)
2,168 Results
N/A
N/A
2,150 Results
1,083 Results
N/A
181 Results
N/A
N/A
N/A
23 Results
N/A
N/A
19 Results
N/A
N/A
23 Results
N/A
2 Results
N/A
N/A
20 Results
18 Results
N/A
N/A
N/A
N/A
N/A
N/A
163 Results
N/A
N/A
10 Results
67 Results
GRADUATE NURSE EMPOWERMENT WITHIN ROLE SOCIALIZATION
15
Appendix B
Model: Defining Attributes of Nurse Empowerment during Role Socialization
Access to
information
Competence
Impact
Support
Autonomy
Informal Power
Meaning
Learning
Opportunities
Formal Power
Resources
Psychological
Structural/organizational
Empowerment
Empowerment
Empowerment
during Role
Socialization
GRADUATE NURSE EMPOWERMENT WITHIN ROLE SOCIALIZATION
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Appendix C
Table 1. Empowerment Approaches for Acute Care Nursing
Awareness
 Foster a unit culture in which free communication and positive feedback are promoted
(e.g., place an “Empower Nursing” suggestion box and a “Best Practice in Nursing”
suggestion box on each unit)
 Examine language and social behavior to ascertain how it fosters the unit culture and
inter/intraprofessional relations
 Provide peer support groups for nursing graduates (NGs) in their transition to
professional practice
 Plan regular unit-level meetings with NGs, seasoned nurses (SNs), and nursing unit
managers (NUMs) to discuss professional opportunities and constraints, and explore
taken-for-granted assumptions about nursing
 Revisit the reward system for enabling the silence of nurses
 Reward challenge rather than enable complacency
 Use direct-care nursing groups to generate unique workload and staffing initiatives that
test the application of unit-specific models of human resource management and nursing
care delivery
 Critique staffing mixture rationale and examine it for suppressive intents that limit the
quality and availability of nursing education, employment opportunities for all staff, and
economic advancement and practice evolution of the nursing profession
 Emphasize evidence-based practice and desired clinical outcomes rather than institutional
convenience when developing nursing practice policies and procedures
 Examine mechanisms available for intradisciplinary and interdisciplinary nursing support
and collaboration
 Critique possible benefits (who stands to benefit and how) for the promotion of ongoing
dissention and divisiveness among multiple levels of nursing staff (nursing aides, NGs,
SNs, NUMs), and between nursing and medicine
Action
 Establish formal and extended (1 year) orientation and transition support programs for
NGs
 Implement formal (sit-down committed time) feedback sessions with NGs and their SN
preceptors/mentors, educators, and managers every shift initially, then reduce to weekly
and monthly thereafter in accordance with clinical progress and workplace comfort level
of the graduate
 Provide collaborative venues for knowledge and expert pattern recognition transfer
between SNs and NGs
 Ensure easy and reliable access for NGs to SN consultation
 Initiate and provide tangible support (work relief, compensation programs) to SNs for
NG mentorship
 Provide clear role descriptions, delineations, and reporting structures for all categories of
nursing staff
GRADUATE NURSE EMPOWERMENT WITHIN ROLE SOCIALIZATION









17
Institute a zero-tolerance policy for horizontal aggression or bullying among nursing staff
or between medicine and nursing
Provide for mutual and codirectional learning experiences between seasoned and novice
unit-based nurses and among nurses and resident/staff physicians
Ensure NG and SN membership on key unit and institutional workplace and clinically
based decision- and policy-making committees
Establish a framework for collaborative clinical role appropriation and workplace
development initiatives between medicine and nursing
Develop an autonomous and collaborative decision-making framework for clinical
nursing interventions aimed at optimizing nurses’ clinical judgment and care decision
appropriation
Establish nurse-directed research initiatives to examine current nursing practice roles and
responsibilities relative to expected clinical outcomes and fiscal unit management
policies or frameworks
Provide for flexible staffing and nursing governance models
Initiate access to Web-based clinical resources for all nursing staff
Make humor and social support in the workplace a priority (e.g., have a “humor board”
and plan regular social activities for staff and their families)
(Boychuk Duchscher & Myrick, 2008, p. 200)
GRADUATE NURSE EMPOWERMENT WITHIN ROLE SOCIALIZATION
Appendix D
Review of Literature Articles
18
GRADUATE NURSE EMPOWERMENT WITHIN ROLE SOCIALIZATION
19
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