Does Organizational Justice Predict Empowerment? Nurses Assess Their Work Environment Liisa Kuokkanen, PhD, RN1 , Helena Leino-Kilpi, PhD, RN2 , Jouko Katajisto, MSSc3 , Tarja Heponiemi, PhD4 , Timo Sinervo, PhD5 , & Marko Elovainio, PhD6 1 Principal Lecturer, Helsinki Metropolia University of Applied Sciences, Metropolia, Finland 2 Professor and Chair, Turku University, Department of Nursing Science, Nurse Manager Hospital District of Southwest Finland, Turku, Finland 3 Senior Lecturer, Turku University, Department of Statistics, Turku, Finland 4 Senior Researcher, National Institute for Health and Welfare, Helsinki, Finland 5 Senior Researcher, National Institute for Health and Welfare, Helsinki, Finland 6 Research Professor, National Institute for Health and Welfare, Helsinki, Finland

Key words Nurse empowerment, organizational justice, nurses’ work environment Correspondence Dr. Liisa Kuokkanen, Helsinki Metropolia University of Applied Sciences, PO Box 4030, FI-00079 Metropolia, Finland. E-mail: [email protected] Accepted: April 13, 2014 doi: 10.1111/jnu.12091

Abstract Purpose: The purpose of the study was to explore how nurses assess their empowerment and clarify organizational justice compared to other work-related factors. In addition, we examined the major variables pertinent to empowerment. Design: Cross-sectional survey data were used. Methods: A total of 2,152 nurses returned the completed questionnaire. The instruments consisted of nurse empowerment, organizational justice, job control, and possibilities for developing work. The data analysis was based on descriptive statistics and further statistical tests. Findings: Organizational justice and empowerment had a clear correlation. Job control, possibilities for developing work and organizational justice were statistically significant predictors of nurse empowerment. Conclusions: Organizational justice and the possibility to use one’s individual skills at work are significant factors in staff activity and its development in nursing. They increase the level of empowerment and commitment as well as motivation to work. Clinical Relevance: The results of this study confirm that nurses regard organizational justice as highly important. We can facilitate both work-related empowerment and organizational justice by creating and maintaining a culture of fairness and justice. Employees should be heard and involved more in the planning and decision making of work.

The development of technology and the demand for efficiency have created a constant pressure for change in healthcare organizations. Work environment plays an important role in this autonomy as well as learning possibilities at work (Schmalenberg & Kramer, 2008). Employees expect encouragement and support from their management, who is also responsible for good working facilities (Stuenkel, Nguyen, & Cohen, 2007). Furthermore, employees want progress. From the employee’s perspective, significant elements include initiative and

Journal of Nursing Scholarship, 2014; 46:5, 349–356.  C 2014 Sigma Theta Tau International

to be active and have the opportunity to influence their own work and expand their individual capacities (Malloy & Penprase, 2010). In the context of nursing research, empowerment has been associated with nurses’ professional development and good leadership (MacPhee, Skelton-Green, Bouthillette, & Suryaprakash, 2012). Currently, only a few nursing research reports exist on organizational justice (Heponiemi et al., 2007; Laschinger, 2004). The present article reports a study in which nurses assessed their empowerment as well as


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explains and analyzes the relationship between empowerment and organizational justice, including work-related and demographic variables.

Table 1. The Factors of Performance of an Empowered Nurse and of Promoting Empowerment Performance of an empowered nurse

Promote empowerment


Moral principles Treats others with respect Acts honestly Acts justly Personal integrity Looks after own well-being Dares to say and act Acts effectively under pressure Acts flexibly Expertise Acts skillfully Makes decisions Acts independently Consults and teaches colleagues Future-orientedness Finds creative solutions Promotes new ideas at work Acts after planning, assesses effects Sociability Discusses openly Works for the common goal Solves problems

Moral principles Shared values Esteem for others Concerted care philosophy Personal integrity Delegated responsibilities Confidence Feedback Expertise Evaluation and development Cooperation Training Future-orientedness Continuity of work Position opportunities Access to information Sociability Collegial support Problem solving Open ambience

Empowerment The concept of empowerment has been used in describing both an essential part of human nature and development on one hand, and the aspects of organizational effectiveness and quality on the other. In literature, empowerment has been described from three aspects using critical social, organizational, and psychological theories (Chen & Chen, 2008; Kuokkanen & Leino-Kilpi, 2000). The individual empowerment process consists of both critical introspection and outside guidance, leading to an appropriate modifying action. The psychological model of empowerment (Thomas & Velthouse, 1990) formed the framework for the qualitative study introducing theme-based interviews relevant to empowerment. The results of this study are shown in the Model of Nurse Empowerment. It describes what an empowered nurse is like (i.e., qualities of an empowered nurse [QEN]) and how he or she performs his or her tasks in relation to the empowerment promoting and impeding factors. Moreover, five categories were formed based on these factors, comprising moral principles, personal integrity, expertise, future-orientedness, and sociability (Kuokkanen, 2003; Kuokkanen & Leino-Kilpi, 2001). Two of the factors, Performance of an Empowered Nurse (PEN) and Work-related Empowerment Promoting factor (WEP), were adopted as the conceptual framework for the questionnaire used in the present study (Table 1). Earlier studies demonstrated that empowerment correlates positively to several factors of work environment: job satisfaction and organizational commitment (Ahmad & Ositadimma Oranye, 2010; Kuokkanen & Katajisto, ¨ onen, ¨ 2003; Kuokkanen, Suominen, Hark Kukkurainen, & Irvine Doran, 2009), education (Piazza, Donahue, Dykes, Griffin, & Fitzpatrick, 2006), and innovative behavior (Knol & Linge, 2008). Many studies approach empowerment from the point of view of organizational structures (Gilbert, Laschinger, & Leiter, 2010; Lautizi, Laschinger, & Ravazzolo, 2009). Nurses wish to be evolved in and exert influence upon their work on the personal level, too (Schmalenberg & Kramer, 2008). There is a need for further and more extensive study on this endeavor of individual nurses.

Organizational Justice The concept “organizational justice” refers to the extent to which employees are treated with justice at 350

Note. Data from Kuokkanen and Leino-Kilpi (2001) and Kuokkanen (2003).

their workplace. It has been traditionally defined in terms of perceptions of fairness and their impact on behavior in organizations (Moorman, 1991). Colquitt and Shaw (2005) described three distinct categories of the concept: distributive, procedural, and interactional justice. The instrument used in this study is based on these three types of organizational justice. Distributive justice means balance between people’s perceived contributions or inputs relative to the outcome they receive from the organization. Procedural justice concerns the perceived fairness of the process by which outcomes are determined. Interactional justice refers to the perceived quality of interpersonal treatment people receive from authority figures. The two dimensions of the third category are interpersonal and informational justice. The first refers to the extent to which individuals are treated with respect and dignity, and the second denotes the extent to which individuals get relevant information on how the decisions affecting them are made. Organizational justice has an impact on social behavior in the workplace. Moreover, justice has an impact on employees’ state of health and how they determine it. Earlier research found a connection between organi¨ zational justice and absenteeism (Elovainio, Kivimaki, & Vahtera, 2002), respect (Laschinger, 2004), productivity (Heponiemi et al., 2007), self-rated health and burnout Journal of Nursing Scholarship, 2014; 46:5, 349–356.  C 2014 Sigma Theta Tau International

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(Liljegren & Ekberg, 2009), intention to stay (Griffin, 2010), and workplace aggression (St-Pierre & Holmes, 2010). Respect and fair treatment of others are values also cherished in nursing. However, only two previous studies within the context of nursing can be found on organizational justice (Heponiemi et al., 2007; Laschinger, 2004).

Aim The purpose of the study was to clarify how nurses assessed their empowerment, which work-related (organizational justice, job control, possibilities for developing work, shift work schedule, employment sector, work tenure, period of employment) and demographic factors (gender, age, education) were connected to empowerment, and which variables explained nurse empowerment most significantly.

Methods Instruments Used to Measure Study Variables Empowerment was measured using the Nurse Empowerment Scale based on five categories representing moral principles, personal integrity, expertise, futureorientedness, and sociability obtained from an earlier qualitative study (Kuokkanen & Leino-Kilpi, 2001). The questionnaire contained two scales (a) PEN (19 items) and (b) WEP (18 items). The content, criterion-related, and construct validities were tested in an earlier study of Kuokkanen (2003). Reliability alpha coefficient have varied between 0.87–0.88 (PEN) and between 0.89–0.92 (WEP) in earlier studies (Kuokkanen & Katajisto 2003, Kuokkanen et al., 2007, 2009). For this sample, reliability alpha coefficients were 0.86 (PEN) and 0.92 (WEP). The items were rated on a 5-point Likert scale, ranging from 1 (totally disagree) to 5 (totally agree), with high values of the average of subscale scores indicating high empowerment. Organizational justice was assessed with a questionnaire developed by Colquitt (2001) and Colquitt and Shaw (2005). As stated earlier, three categories represented organizational justice. First, procedural justice contained seven items. The reliability α coefficient for this sample was 0.92. Second, interactional justice was divided into two distinct dimensions: interpersonal justice with four items and informational justice with five items. The reliability α for these second and third dimensions together was 0.96. Third, distributional justice contained four items. The reliability α coefficient here was 0.97. The items were rated on a 5-point Likert scale, ranging from 1 (totally disagree) to 5 (totally agree), with higher values of the average of subscale scores indicating higher justice. Journal of Nursing Scholarship, 2014; 46:5, 349–356.  C 2014 Sigma Theta Tau International

Job control was measured by using the two scales of skill discretion (six items) and decision authority (three items) derived from Karasek’s Job Content Questionnaire (Karasek, 1985). Skill discretion measures skills level, creativity, task variety, and learning new skills. Decision authority measures the level of making independent decisions and possibilities to choose how to perform at work. The items were rated on a 5-point Likert scale, ranging from 1 (totally disagree) to 5 (totally agree). The reliability α for this sample was 0.81. As for the questions regarding possibilities for developing work (eight items), the focus was on how to influence one’s own work (e.g., planning, organization of work, and making acquisitions). The reliability α for this sample was 0.87.

Other Variables Nurses were asked about their shift work schedule (work during business hours or shifts), gender, age, education (bachelor of science in nursing [BSN], specialized nurse [BSN plus further education], and master’s of nursing science), employment sector (public hospital, public health center, public elderly care, other, entrepreneur), work tenure (permanent or temporary) and period of employment.

Sample and Data Collection A random sample of 5,000 registered nurses were selected from the database of Finnish nurses covering all 45,000 registered nurses in Finland and maintained by the National Supervisory Authority for Welfare and Health. A self-administered questionnaire was sent by post. Nonrespondents were sent up to two reminders along with a further copy of the questionnaire. A total of 2,152 nurses (43%) completed and returned the questionnaire. Most of them were female (95%) and worked in hospitals (42%). Respondents’ mean age was 42 years (range 23–60 years). Their characteristics are shown in Table 2. The sample is representative of the eligible population in terms of age (mean = 42.8), gender (96% women), and employment sector (42% work in hospitals).

Ethical Considerations The ethics committee of the National Research and Development Centre for Welfare and Health approved the study, and written informed consent was obtained from each participant. Participants cannot be identified from the results because their personal details were deleted after entering the returned surveys in the database and 351

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Table 2. Respondents’ Characteristics (N = 2,152) n


1,881 62 190

88 3 9

899 540 153 107 23 282

45 27 8 5 1 14

Age Mean 42 years (range 23–60) Education BSN and special nurse MNSc Other Employment sector Hospital Health station Elderly care/rehabilitation Private hospital and health care Entrepreneur Other (educational institute, home for elderly care, etc.) Work tenure Permanent whole day Nonpermanent whole day Part time Other Work schedule Work during business hours Shift work Other

1,440 289 99 94

68 14 5 4

885 1,080 112

43 52 5

Note. BSN = bachelor of science in nursing; MNSc = master’s of nursing science.

checking the accuracy of the data entry. The cover letter clarified the background of the study and also provided contact details in case of further questions about the study.

Statistical Analysis Data analysis was based on descriptive statistics and statistical tests using the Statistical Package for Social Sciences 16.0 for Windows (SPSS Inc., Chicago, IL, USA). Sum variables were formed according to the theoretical categories. The reliability of sum variables was measured by calculating Cronbach’s α coefficients and examining the compatibility of single questions with the instrument by using an item analysis. The sample size was large enough (central limit theorem) to use parametric tests without concerns of normality assumptions. Skewness was checked to be in the same direction when comparing two groups using parametric or nonparametric tests. Parametric tests have more power to reveal statistically significant differences or associations between groups and they should be used when possible. When the background variable only had two groups compared to more than two groups, the independent samples t test was used to compare the mean scores. For multigroup background variables, comparisons of groups were 352

made using the one-way analysis of variance (ANOVA) with post-hoc tests, Tukey’s test, or Tamhane’s test, depending on the result of the homogeneity of variance test. Dependence between background variables and individual items were analyzed with the Pearson chi square test or Fisher’s exact test. Analysis of variance with continuous variables as covariates (ANCOVA/general linear model) was used when examining the major factors explaining empowerment. The observed significance level of

Does organizational justice predict empowerment? Nurses assess their work environment.

The purpose of the study was to explore how nurses assess their empowerment and clarify organizational justice compared to other work-related factors...
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