Critical Care Staff Nurses: Empowerment, Certification, and Intent to Leave

The conceptualization for the original study²  was based on Laschinger’s³  interpretation of Kanter’s theory.⁴  Extending Kanter’s theory and relating it to nursing, Laschinger posited that an individual’s perceptions of empowerment were based on perceptions of access to opportunities, information, support, resources, informal power, and formal power. Both Kanter and Laschinger refer to this concept as structural empowerment. Further, Laschinger proposed that higher levels of structural empowerment among individuals within an organization result in employees who help achieve organizational goals, have greater commitment, and have higher job satisfaction. Laschinger and colleagues have conducted several studies of the relationship between perceptions of structural empowerment and other organizational characteristics, including, for example, Magnet hospital status,⁵  burnout,^{6, 7}  job satisfaction,⁸  and engagement.⁹  Most of the research by Laschinger and her colleagues has been done in Canada.

In a small study based on the research of Laschinger and colleagues, Piazza et al¹⁰  found that structural empowerment in a community hospital differed between nurses who were nationally certified and nurses who were not. The certified nurses had higher levels of structural empowerment. In that study,¹⁰  all nurses were included in the sample regardless of their position in the organization. This small study¹⁰  sparked the interest of the AACN Certification Corporation and led to our research. We wished to determine whether the findings of Piazza et al would be supported by the results of a study of a national sample of critical care nurses. We also wished to determine whether certification status would be associated with differences in intent to leave.

Certification research has been linked primarily to intrinsic factors such as personal satisfaction and professional growth.^{11, 12}  After reviewing the research on specialty certification in nursing, Wade¹²  concluded that certification has both intrinsic (eg, nurses’ satisfaction, professional growth, empowerment) and extrinsic (eg, organizational commitment, retention, and patients’ satisfaction) rewards. Little research has been done on nurses’ intent to leave their current position (IL-CP) and on their intent to leave the nursing profession (IL-NP) as related to the certification status of the nurses. In addition, research has been limited on the certification status of staff nurses only.

In a national study¹¹  conducted by the American Board of Nursing Specialties to validate nurses’ perceptions, values, and behaviors related to certification, the researchers found no differences in IL-CP between certified and noncertified nurses. Zurmehly et al¹³  found a significant inverse relationship between empowerment and IL-CP (P<.001) and empowerment and IL-NP (P<.001) but did not consider the certification status of the nurses. Nurses who indicated that they intended to leave the profession had lower empowerment scores than those who did not intend to leave.

In a sample of 908 nurses obtained from a Web-based survey posted on the Nursing Spectrum publication’s Web site, Nogueras¹⁴  found a significant relationship between IL-NP and affective occupational commitment (ie, nurses’ emotional attachment to their organization; P<.001), continued occupational commitment (ie, nurses’ perceptions of the costs of leaving the organization; P<.001), and normative occupational commitment (ie, nurses’ perceptions of obligations to the organization; P<.001). Overall, when occupational commitment increased, IL-NP decreased. However, Nogueras did not include certification as a variable, and the sample did not consist solely of staff nurses.

Because of the increased interest of AACN in promoting specialty certification among staff nurses, we extracted the data on staff nurses from the larger data set²  in which differences in empowerment were found between nurses who were AACN certified and nurses who were not. We were particularly interested in determining whether AACN certification would correlate with the same significant differences among staff nurses only. Thus, in the analyses presented here, we determined if differences in empowerment and IL-CP and empowerment and IL-NP differed between staff nurses who were AACN certified and those who were not. The specific research questions for the study were as follows:

1. Are there differences in perceptions of structural empowerment between staff nurses who are AACN certified and staff nurses who are not?

2. Are there differences in IL-CP between staff nurses who are AACN certified and staff nurses who are not?

3. Are there differences in IL-NP between staff nurses who are AACN certified and staff nurses who are not?

Data from a Web-based survey²  of AACN members were examined in a descriptive comparative quantitative study. After approval for the survey was obtained from the institutional review board of the university of the primary investigator (J. J. F.), an invitation letter to participate in the study was sent to the 44143 AACN members in the AACN e-mail database. Reminder e-mails were sent 2 weeks later and 1 week before the study closed. The survey site was left open for a total of 4 weeks.

To encourage participation, AACN members had the option of participating in a drawing for free registration to the AACN National Teaching Institute and Critical Care Exposition. The names and contact information of those who participated in the drawing were kept separate from the study data and were destroyed after the drawing. Participation in the drawing was not a requirement to participate in the study. In order to maximize data obtained on the empowerment variable, the empowerment questionnaire was placed first and was followed by a background questionnaire used to obtain demographic data, certification status, IL-CP, and IL-NP.

Personal and professional background characteristics included age, sex, ethnicity, years of experience, highest level of education, AACN certification, and other nursing specialty or subspecialty certifications (eg, certification at any advanced practice level and certification in any other specialty area, such as oncology, emergency, or perioperative nursing).

The Conditions of Work Effectiveness Revised (CWEQ-II)¹⁵  developed by Laschinger et al was used to measure empowerment. This 19-item instrument is used to measure the components of empowerment included in Kanter’s theory.^{4, 16}  Using a Likert format, respondents rate the extent to which they have access to 6 empowerment dimensions within their organizations: opportunity, information, support, resources, formal power, and informal power. Each dimension is a subscale of the instrument; total scale scores range from 6 to 30, and each subscale score ranges from 1 to 5. In previous research,¹⁶  the Cronbach reliability coefficient for the CWEQ-II has ranged from 0.78 to 0.93. In our major study²  of critical care nurses, the reliability of the CWEQ-II was r=0.91. The Cronbach α for the staff-nurse-only sample for the CWEQ-II total score also was 0.91, indicating high reliability of the instrument. Subscale α values ranged from 0.75 to 0.91.

Frequency, percentages, means, and standard deviations were calculated for the key study variables (AACN certification, empowerment, IL-CP, and IL-NP). AACN certification was defined by a self-reported yes response to AACN certification for any of the following: CCRN, PCCN, CCNS, CSC, and CMC. Empowerment was defined as the total score on the CWEQ-II (sub-scale scores were computed for additional descriptive analyses). IL-CP and IL-NP were measured as the number of self-reported yes or no responses to the following questions: Do you intend to leave your current position, and Do you intend to leave the nursing profession? If a respondent answered yes to either of these questions, then he or she was asked the time frame for intent to leave, ranging from within the next year to within 5 years. Several other researchers have used intent-to-leave variables, and face validity has been accepted.^{2, 11, 13}  Differences between groups on the key study variables were analyzed by using t tests.

The total response rate was 15%.²  Of the total responses (n=6589), 4268 were from staff nurses; thus 65% of the total sample consisted of staff nurses. Detailed characteristics of the staff-nurse-only sample are presented in the Table.

A total of 2268 of the staff nurses were AACN certified (53%), and 2000 were not (47%). Differences in total empowerment scores between nurses who were AACN certified and nurses who were not were not significant. Mean total empowerment scores for both groups were in the moderate empowerment range (14–22). Scores on the sub-scale of informal power were significantly higher for staff nurses who were AACN certified than for those who were not (t=−4.63; P=.001) Staff nurses who were not AACN certified had significantly higher scores on subscales of opportunity (t=2.64; P = .01) and support (t= 2.24; P = .03).

In addition to being asked about AACN certification, nurses were asked if they had any national certification. The groups were then divided into those who had any national certification (AACN and/or other; n=2873) and those who did not (n= 1395). Total empowerment scores between these 2 groups did not differ significantly; however, those who held any national certification had significantly higher informal power scores (t=2.83; P=.005). Again, the range of scores of both the nationally certified staff nurses and those without national certification were in the range of moderate empowerment (14–22).

IL-CP and IL-NP did not differ significantly between staff nurses who were AACN certified and those who were not. Further, when the certification groups were divided into those who had any national certification and those who had no national certification, differences between these 2 groups in either IL-CP or IL-NP were not significant.

Although total empowerment scores did not differ significantly between staff nurses who were AACN certified and staff nurses who were not, the significant differences in perceptions of informal power, opportunity, and support are of interest. According to Kanter’s model,⁴  informal power is the ability to form effective alliances with others in the organization, independent of one’s position. Persons who perceive that they have more informal power also may perceive greater capacity to get things done, a perception that could have many ramifications in patient care delivery. Certainly, informal power is an important avenue for future research.

Staff nurses without AACN certification had higher scores on opportunity and support dimensions than did staff nurses with AACN certification. According to Kanter’s model,⁴  access to opportunity is the perception of a chance for growth within the organization and support is being able to engage in activities within the organizational structure. In our study, we did not determine reasons for certification and plans for future certification. These additional dimensions may be valuable in gaining a more in-depth understanding of the relationship between individual nurse certification and empowerment structures within health care organizations.

In this sample of staff nurses only, the findings of differences according to certification are in contrast to the findings reported for the total sample of AACN nurses surveyed (n=6589).²  In the main study,²  which included staff nurses and nurses in a range of other positions, both total empowerment scores and IL-CP differed significantly between nurses who were AACN certified and those who were not. Compared with nurses who were not AACN certified, nurses who were had higher perceptions of empowerment and were less likely to leave their position.²  The findings in the main study may be related to the educational level of nurses in positions other than staff nurses or to a combination of education and position. Both the factors related to perceptions of empowerment and why nurses intend to leave their position are complex and warrant further study.

Although the survey in the main study²  was available to all AACN members, as with other survey research, nurses who were interested in research may have been more likely to respond than were other nurses. Also, the sample included a high percentage (72.2%) of staff nurses with bachelor of science in nursing or higher degrees. National data¹⁷  indicate that only 47.2% of registered nurses have a bachelor of science in nursing or higher degrees. Thus, our results cannot be generalized to the larger population. Also, the self-report measures used in the study might have contributed to a common method bias reflected in upwardly biased results.

Our focus on staff nurses provides additional insights into the relationships between specialty certification, empowerment, and IL-CP and IL-NP. At the same time, our results indicate that extension of the research into other dimensions of the work life of staff nurses is needed, particularly characteristics of the work environment that would be conducive to increased retention.

We made no attempt to determine reasons for IL-CP. Future research should be focused on determining factors that might lead staff nurses to stay in their positions. In particular, with the current economic downturn, determining both external factors and organizational factors that might lead to greater retention of staff nurses would be useful. Studies to uncover those factors would provide valuable information for the design of orientation programs for new nurses and retention programs for experienced nurses. The relationships between empowerment, certification, and patient outcomes also should be studied. Assessment and evaluation of institutional retention programs as related to staff nurse empowerment, IL-CP, and IL-NP also are recommended.

Although we found no differences in empowerment according to certification status, other reasons for certification have been identified, including several personal factors such as satisfaction and professional growth.^{1, 11}  These intrinsic rewards are important reasons for staff nurses to become certified. In a survey¹¹  of more than 11000 certified and non-certified nurses, including staff nurses, by the American Board of Nursing Specialties, more than 90% of the nurses agreed that certification validates specialized knowledge, enhances professional credibility, and indicates a level of clinical competence. More than 80% indicated that certification promotes recognition from peers and other health professionals. According to AACN,¹  key values of certification are providing the individual nurse with a sense of pride and accomplishment, demonstrating a commitment to the profession and to lifelong learning, and assuring consumers that nurses have met recognized standards. Certification may be more about individual and professional values than about the relationship of the individual nurse to the institution in which he or she works.

Efforts should be made to involve staff nurses in the institutional components that enhance empowerment. This involvement can be accomplished through a variety of structures and processes within professional practice models. Nurses who have a voice and actively participate in their own institutional work life will be more likely to stay in their positions. At a time when retention of professional nurses is an important goal for all health care institutions, enhancing staff nurses’ perceptions of structural empowerment is important.

Certification is generally accepted as a mark of professional excellence.^{1, 11}  Comparisons between certified and noncertified staff nurses did not show differences in either total empowerment or IL-CP, although differences were noted among several factors associated with empowerment. Our findings contribute to knowledge about staff nurses, particularly, key information about the relationship between empowerment and IL-CP. The benefits of certification for staff nurses warrant further research. Continued study should focus on linkages between certification and professional identity of staff nurses and on the relationship between certification and patient outcomes.