Work engagement, psychological empowerment and relational coordination in long-term care: A mixed-method examination of nurses' perceptions and experiences
Abstract
Nurse engagement, empowerment and strong relationships among staff, residents and families, are essential to attract and retain a suitably qualified and skilled nursing workforce for safe, quality care. There is, however, limited research that explores engagement, empowerment and relational coordination in long-term care (LTC). Nurses from an older persons’ mental health and dementia LTC unit in Australia participated in this study. Forty-one nurses completed a survey measuring psychological empowerment, work engagement and relational coordination. Twenty-nine nurses participated in individual interviews to further explore these concepts. Although nurses reported high psychological empowerment and work engagement, their relationships with key stakeholders varied. Our findings suggest that nurses in LTC require both supports and opportunities to contribute as active members of the multiprofessional care team that includes tailored education, professional development and positive interactions within the care team. Regular support is needed to enable nurses to feel empowered, foster relationships and communication, and facilitate work engagement. Based on these findings, we suggest that it is important to find ways to ensure that all who provide care perceive that they are part of the whole care team and able to contribute to the care and well-being of people in LTC.
1 INTRODUCTION
Supporting the care needs of older people is a global concern. Rapidly ageing populations with ever more complex care needs are increasing demand for expert long-term care (LTC) (van Gaans & Dent, 2018). The recruitment and retention of employees with the appropriate qualifications, knowledge and skills to provide high-quality care for older people in LTC present a significant and ongoing challenge for service providers (Commonwealth of Australia, 2018, 2021; Gillham et al., 2018; Pijl-Zieber et al., 2018). Empowerment, work engagement and interpersonal relationships among healthcare teams are essential to support high-quality care, healthy work environments and, ultimately, nurse retention (Al Zamel et al., 2020; Wei et al., 2018). Much of the research regarding engagement, empowerment and relational coordination (i.e., communication and collaboration among the care team) in nursing has been conducted in the acute care setting (DeVivo et al., 2013; Meng et al., 2016; Ranjbar & Gorji, 2018; Redley et al., 2021), with less evidence available for the LTC setting; there does not appear to be any research that explores all three concepts concurrently in the LTC setting. This study sought to address this gap by measuring nurses’ self-reported work engagement, psychological empowerment and relational coordination in LTC and exploring their perceptions of what nurses in LTC need to feel empowered.
Internationally, the population is ageing. Across the Organisation for Economic Co-operation and Development (OECD) countries, it is expected that between 2019 and 2050 the proportion of people aged 65 years and older will increase from 17.3% to 26.7% (Organisation for Economic Co-operation and Development, 2021). Moreover, the proportion of people aged 80 years and older will more than double from 4.6% to 9.8% (Organisation for Economic Co-operation and Development [OECD], 2021). This ageing population is driving demand for LTC, with an 11% increase in permanent LTC between 2011 and 2021 in Australia (Australian Institute of Health and Welfare, 2022). Older people are choosing, and being supported, to stay in their own homes for as long as possible (Australian Institute of Health and Welfare, 2021; OECD, 2021). This support may include nursing care alongside other services designed to assist people to remain independent, stay in their homes and continue to be connected to their local community. Consequently, those entering LTC often do so very late in life when they are very frail, with complex physical, cognitive and well-being care needs (Eagar et al., 2020). The increasingly complex care needs of older people living in LTC require staff with the commensurate expertise and qualifications to provide safe, quality care. But recruiting and retaining suitably qualified and skilled LTC workers to provide high-quality care remains a longstanding global challenge (Commonwealth of Australia, 2018, 2021; Gillham et al., 2018; Pijl-Zieber et al., 2018).
Highly engaged staff is fundamental to recruitment and retention and, ultimately, the provision of high-quality care (Aged Care Workforce Strategy Taskforce, 2018). Work engagement is described as a persistent 'positive, fulfilling work-related state of mind that is characterised by vigour, dedication and absorption' (Schaufeli et al., 2006, p. 702); as such, work engagement can be considered the opposite of burnout, which is an emerging challenge. The positive approach of employees who are engaged means that they are more inclined to consider difficult work to be challenging rather than stressful or demanding (Bakker et al., 2014). Highly engaged employees are more likely to stay with their organisation, provide a quality service, and contribute to improved organisation performance (Aged Care Workforce Strategy Taskforce, 2018).
Alongside engagement, empowerment among nurses is increasingly being recognised for its positive relationship with high levels of autonomy and work effectiveness (DeVivo et al., 2013). Psychological empowerment has been described as a cognitive state that is characterised by a sense of control, competence and goal internalisation (Saleh et al., 2022). In this way, it differs from structural empowerment, which is described as the workplace conditions that encourage employees to perform at their optimal level, supported by requisite information and resources to learn and grow (Saleh et al., 2022). Psychological empowerment is thought to comprise four key elements: meaning, competence, self-determination and impact (Saleh et al., 2022). Nurses who are empowered are assertive, innovative and engaged, and advocate for their care recipients (Redley et al., 2021).
Empowerment has positive associations with interprofessional collaboration among healthcare professionals (Karukivi et al., 2023). Relational coordination offers one theory to explore the teamwork processes of communicating and relating among the healthcare team to provide care (Bolton et al., 2021). The premise of relational coordination is that relationships among the team that are characterised by shared knowledge, shared goals and mutual respect can facilitate 'frequent, timely, accurate, problem-solving communication' that allows all team members to more effectively coordinate their work (Bolton et al., 2021, p. 293).
Two recent reviews concluded that relational coordination among interdisciplinary healthcare staff is associated with positive outcomes in terms of care quality and efficiency (Bolton et al., 2021), learning and innovation among the healthcare team (Bolton et al., 2021; House et al., 2022), staff well-being (Bolton et al., 2021), work engagement (Bolton et al., 2021; House et al., 2022) and job satisfaction, burnout and retention (House et al., 2022). In the LTC setting, relational coordination has been demonstrated to predict job satisfaction among nursing aides and quality of life among residents (Gittell et al., 2008). Relational coordination is particularly important in settings such as LTC where tasks require communication and collaboration among staff to be completed (Tingvold & Munkejord, 2021).
Much of the research on psychological empowerment, work engagement and relational coordination among nurses has focussed on acute hospital settings and there is limited evidence from the LTC sector. In an effort to address this gap, the aims of this study were to, (i) measure nurses’ self-reported empowerment, work engagement and relational coordination when caring for residents in LTC; (ii) explore enablers and barriers to nurse engagement with the multiprofessional care team, residents and families and (iii) identify what nurses need to feel empowered and engaged in LTC.
2 METHODS
2.1 Design
We used an interpretivist mixed-method design (McChesney & Aldridge, 2019), comprising a self-report survey followed by individual in-depth interviews. This approach allowed for both measurement and in-depth exploration to understand empowerment, engagement and relational coordination from the perspective of nurses in LTC.
2.2 Ethical considerations
This study was conducted in accordance with the ethical principles of the National Statement on Ethical Conduct in Human Research in Australia (National Health and Medical Research Council, 2007, Updated 2018), and received ethical approval from the health service's Human Research Ethics Committee (approval number RES-19-0000547L-55800). Participation in this study was voluntary; the nurses received a detailed participant information and consent document and had an opportunity to attend in-person information sessions with the research team. Researchers were not directly involved in participant recruitment; the Nurse Unit Manager (NUM) distributed the research invitation to participants and was subsequently unaware of which staff volunteered to participate. For the survey, consent was implied by the return of a completed survey. All interview participants had an opportunity to ask questions and provided informed written consent before the commencement of their interview. Survey responses were anonymous and all interview transcripts were deidentified to maintain anonymity. Anonymity and confidentiality were further protected by the reporting of findings in aggregate form.
2.3 Setting and participants
The setting was a 40-bed older persons’ mental health and dementia LTC unit within a large metropolitan health service in the State of Victoria, Australia. All care staff in this unit were nurses, both Registered Nurses (RN) and Enroled Nurses (EN), with ENs comprising approximately 80% of the nursing workforce. In Australia, RNs have typically completed a 3-year Bachelor degree and ENs complete a 12–18 months Diploma of Nursing. EN work under direct or indirect supervision of an RN (Nursing and Midwifery Board of Australia, 2016) and all ENs in the sample had completed the requisite education to administer medication. In this LTC unit, the ‘RN’ cohort included RNs, Associate Nurse Unit Managers (ANUMs) working in a senior clinical role, and RN Graduates undertaking a 12-month Graduate Nurse programme in their first year of clinical practice after completing their degree (Tuckett et al., 2017). All eligible nurses employed in the unit at the time of data collection (n = 47) were invited to participate in the survey. Purposeful recruitment of up to 30 individuals for interviews provided maximum variation in nurse characteristics such as age, designation (RN or EN), culture and language diversity, country of birth, place where initial nurse training was completed and length of time working in LTC.
2.4 Recruitment and data collection
Data collection occurred between September 2019 and March 2020, before the start of the coronavirus disease 2019 (COVID-19) pandemic in Australia. The first author (H. R.), an RN with clinical and research experience in LTC, discussed recruitment with the NUM. The first author held information sessions at suitable times in the unit (i.e., regular meeting, before or after shift change handover), to provide nurses with a verbal overview of the study, answer questions and distribute copies of the Participant Information and Consent Form. On behalf of the researchers, the NUM sent an email invitation that contained the Participant Information document and a link to the anonymous online survey to all nursing staff. To reduce sampling bias associated with an online survey, nurses were advised that they could complete the survey either online or using a paper-based version of the survey which was available for collection in the staff room and returned to researchers using a designated box. Only five participants completed the survey online; the remaining surveys were paper-based. The survey was available for completion for 8 weeks. A reminder email was sent to staff 3 weeks after the first email and then 1 week before the survey recruitment closed. Before recruitment for the interviews, the first author presented summary survey results to the nurses at information sessions, and nurses were invited to contact the researchers if they were interested to participate in an interview. Consistent with the research design, the staged sequential process assisted researchers to identify topics for inclusion in the interview guide.
Contact details provided by the nurses were used to schedule a mutually agreeable date and time for an interview. The nurses were selected to be interviewed in a private room at the unit. Before the interview, a further explanation about the study's purpose and requirements for participation was provided to the participant and any questions answered before the nurse signed a consent form in the presence of the interviewer. The interviews were facilitated by the first author, supported by a research assistant an RN with clinical experience in LTC. The interviews were recorded using digital voice recorders and were between 30 and 50 min duration. Identifying information was removed during transcription and each interview was allocated an anonymous code number.
2.5 Survey tool
- (i)
Spreitzer's psychological empowerment scale (PES) (Spreitzer, 1995), a 12-item scale to measure nurses’ perceptions of psychological empowerment in their workplace. This scale has been widely used in research with nurses (DeVivo et al., 2013; Meng et al., 2016; Ranjbar & Gorji, 2018; Redley et al., 2021). The scale has four subscale dimensions, with three items in each dimension: Meaning—perceptions of how meaningful and important the work is; Competence—confidence in their abilities and having the required skills to do the job; Self-determination—having autonomy and ability to make decisions in work; Impact—having influence and control over what goes on at work. Each item is rated using a 7-point Likert scale with responses ranging from 1 = very strongly disagree to 7 = very strongly agree. A score of 5 or more indicates high empowerment. Total psychological empowerment scores are obtained by averaging the total subscale scores, with high mean scores indicating high perceived levels of psychological empowerment.
- (ii)
Utrecht Work Engagement Scale (UWES-9) (Schaufeli et al., 2006), the most widely used scale to measure work engagement among nurses (García-Sierra et al., 2016), is a 9-item scale measure using three subscales for the dimensions of work engagement, with three items in each subscale: Vigour—having high level of energy and mental resilience while working, the willingness to invest effort in one's work, and persistence in the face of difficulties; Dedication—being involved in work, finding meaning in work, being challenged and experiencing sense of enthusiasm, inspiration and pride; Absorption—being fully concentrated and engrossed in work. The three subscale dimension scores have previously demonstrated good internal consistency and test-retest reliability (Schaufeli et al., 2006). Each item is rated on a 7-point Likert scale ranging from 0 = never to 6 = always. Each subscale is averaged to produce a total scale score between 0 and 6, with higher scores indicating higher work engagement.
- (iii)
Relational coordination survey (RCS) (Gittell et al., 2015). This 7-item scale was used to measure nurses’ perceptions of relational coordination (i.e., the process of relating and communicating among stakeholders for the effective coordination of work) with specific stakeholder groups in the LTC setting. The scale is a reliable instrument used to identify strengths and weaknesses in teams and has been used in healthcare settings (Gittell et al., 2015; Redley et al., 2021). The relational coordination survey has three dimensions of relating (shared goals, shared knowledge and mutual respect), and four dimensions of communicating (frequent, timely, accurate and problem solving). Each of these seven dimensions is assessed by a single question, but responses are made in relation to each of the different stakeholders relevant to the context. In this setting, this included eight key stakeholder groups that nurses relate to as part of their work providing care residents: other nurses (RNs and ENs), senior nurse management, medical staff, allied health (e.g., physiotherapist), well-being/lifestyle staff, pharmacists and family members. Mean scores for dimensions and stakeholder groups are calculated, and cut-points for strengths of relational ties have been established categorise scores as weak (<3.5), moderate (3.5–4.0), or strong (>4.0).
2.6 Interview guide
The interview guide (Table 1) was developed based on the study aims, concepts of work engagement, nurse empowerment and relational coordination from current literature (DeVivo et al., 2013; Gittell et al., 2015; Schaufeli et al., 2006; Wei et al., 2018), and results from the survey. The RN (S. D., R. Pi.) and EN (R. Pe.) research team members from LTC were involved in developing the interview questions. Topics included perceptions of nurse empowerment, relational coordination in LTC; requirements to feel empowered; and enablers and barriers to engaging with others such as residents, resident families and the multiprofessional care team. In addition, interview participants were presented with key findings from the survey and asked for their perspectives and possible explanations for these findings.
| Topics and guide questions |
|---|
| Nurse empowerment |
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| Work engagement |
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| Relational coordination and teamwork |
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2.7 Data analysis and rigour
Electronic survey data were exported from Qualtrics XM to IBM SPSS® Statistics version 25 for analysis. The composite tool was scored according to the instructions for each individual tool and data were reported descriptively, with Cronbach's ⍺ reported for the PES and UWES-9. Formal comparative analyses based on demographic variables were not feasible due to the unevenness of sample sizes. Nonetheless, the results include a descriptive breakdown of responses for ENs, RN Graduates and ANUM/RNs as this was important in relation to the key concepts of empowerment, work engagement and relational coordination. Missing data were excluded pairwise, to minimise the impact on the sample size.
Interviews were transcribed verbatim by a professional transcription service, checked by H. R. and S. D. for accuracy, and entered into NVivo 20.3 to support organising and analysing the data. The exploratory research topic and data collection method were suited to reflexive thematic analysis techniques as described by Clarke and Braun (2018) using an inductive approach to organise the data to identify related patterns (themes) across the data set. The data were independently coded by authors H. R. and S. D. with support from R. Pi. and R. Pe. Data analysis was an iterative process and involved: becoming familiar with the data through immersion by reading the transcripts and also listening to the audio-recording, and making brief notes; systematically coding the data to identify key labels relevant to the research aims and questions; identifying shared meaning across the coded data set to generate initial themes and subthemes; developing and reviewing the initial themes against the coded data and the complete data set. Authors H. R. and S. D. engaged in ongoing discussions to refine, finalise and name the themes as the fifth step in the analysis approach. Authors C. O., E. M. and B. R. also engaged in the reflexive discussions to further develop and challenge assumptions based on collective nursing experiences in LTC. All authors agreed on the final themes and subthemes.
Rigour was maintained by adopting the principles of credibility, fittingness, auditability and confirmability (Patton, 2015). Credibility was achieved by recruiting nurses based on the stated inclusion criteria and ability to share their experiences of empowerment, engagement and relational coordination in LTC. Other strategies to establish credibility and enhance confirmability include the authors engaging in reflexivity, peer debriefing and presenting participants’ verbatim quotes. The degree of ‘fit’ of the findings from the interviews is affirmed by triangulation of data from the survey and affirmed feedback from the presentation of summary findings in research and health-related forums. Auditability was maintained through an audit trail of the study activities and in accordance with ethics requirements.
3 RESULTS
3.1 Survey participant characteristics
As the study was based at a specific LTC unit at one health service, nurse characteristic information are provided in aggregated form to ensure anonymity. The survey was accessed by 42 of the 47 eligible nurses; note that one case completed only the demographic items without completing any scale items and was thus excluded from analysis resulting in a final sample of 41 respondents (87% response rate). Respondents were aged between 24 and 70 years with a mean age of 45 years (SD = 13.24), and most were female (n = 28, 68%) and employed part time (n = 34, 83%). The majority were ENs (n = 32, 78%), which is consistent with the proportion of ENs employed in the unit; there were four RN Graduates (10%) and a further four RNs/ANUMs (10%) (one respondent did not specify their role). Given the large number of ENs relative to RNs, between-group comparative analyses were not undertaken. Participants had a range of experience working in LTC, from 1 to 30 years, with a mean of 11 years (SD = 8.54), and over one-third (37%, n = 15) had worked in the sector for 5 years or less. The majority of respondents (n = 26, 63%) were born in a country other than Australia (nine individuals did not respond to this question), most commonly in South Asian countries such as India and Sri Lanka, and East and South-east Asian countries such as the Philippines and Malaysia (Figure 1). Almost 60% (n = 24) spoke another language in addition to English.
3.2 Psychological empowerment
The results for the PES are reported in Table 2; mean scores are included for the whole sample and the three staff groups (ANUMs/RNs, RN Graduates, ENs). The mean score for the whole sample was 5.74 (SD = 1.17), indicating high overall psychological empowerment. RN graduates had the highest overall psychological empowerment and the ANUM/RN group had the lowest. Across the four dimensions of empowerment, ‘meaning’ had the highest mean score and ‘impact’ had the lowest, although the mean score of the RN Graduates was considerably higher than both the EN group and the ANUM/RN for the impact dimension.
| Mean (SD) | ||||||
|---|---|---|---|---|---|---|
| Dimension | EN (n = 32) | RN Graduate (n = 4) | ANUM/RN (n = 4) | Total sample (n = 41)a | Cronbach's α | |
| Meaning | 6.46 (0.82) | 6.83 (0.33) | 5.50 (3.00) | 6.40 (1.14) | 0.93 | |
| Competence | 6.23 (0.75) | 5.92 (0.42) | 5.42 (2.95) | 6.14 (1.09) | 0.92 | |
| Self-determination | 5.53 (1.32) | 5.08 (0.69) | 5.17 (2.78) | 5.45 (1.41) | 0.84 | |
| Impact | 4.82 (1.74) | 6.00 (0.82) | 4.75 (2.50) | 4.97 (1.74) | 0.96 | |
| Total score | 5.76 (0.97) | 5.96 (0.14) | 5.23 (2.82) | 5.74 (1.17) | 0.95 | |
- Note: Scoring: Maximum score =7; scores ≥5 represent high psychological empowerment (Spreitzer, 1995).
- Abbreviations: ANUM/RN, Associate Nurse Unit Manager/Registered Nurse; EN, Enroled Nurse; RN Graduate, Registered Nurse Graduate.
- a One respondent did not specify their role so was only included in the total sample results.
3.3 Work engagement
The results for the UWES-9 score are reported in Table 3, including the total Work Engagement score and subscale scores for the whole sample and the three staff groups. The mean UWES-9 score for the sample was 5.53 (SD = 0.84), indicating high work engagement. Across the three dimensions, dedication had the highest overall mean score for the whole sample and across the three staff groups. The absorption dimension also had a high mean score across all groups and the total sample). In contrast, the mean score for vigour was the only dimension with a mean <5 for the overall sample, with the ENs reporting the lowest mean score.
| Mean (SD) | ||||||
|---|---|---|---|---|---|---|
| Dimension | EN (n = 32) | RN Graduate (n = 4) | ANUM/RN (n = 4) | Total sample (n = 41)a | Cronbach's α | |
| Vigour | 4.89 (1.06) | 5.33 (0.90) | 5.50 (0.69) | 4.98 (1.01) | 0.61 | |
| Dedication | 5.92 (1.00) | 6.33 (0.82) | 6.25 (0.42) | 5.97 (0.94) | 0.85 | |
| Absorption | 5.52 (1.16) | 6.00 (0.72) | 5.92 (0.17) | 5.63 (1.07) | 0.85 | |
| Total score | 5.44 (0.90) | 5.89 (0.71) | 5.89 (0.36) | 5.53 (0.84) | 0.86 | |
- Note: Maximum score = 6 with higher scores indicating higher work engagement.
- Abbreviations: ANUM/RN, Associate Nurse Unit Manager/Registered Nurse; EN, Enroled Nurse; RN Graduates, Registered Nurse Graduate.
- a One respondent did not specify their role so was only included in the total sample results.
3.4 Relational coordination
The relational coordination score illustrated in Figure 2, was calculated for each of the three staff groups in relation to eight key stakeholders. The mean relational coordination scores varied from weak (<3.5) to strong (>4) with distinct differences noted among the three participant groups (Table 4). The mean relational coordination scores for the ANUM/RNs group in relation to key stakeholders were strong (>4.0) for seven stakeholders and moderate for the family group (M = 3.56, SD = 0.48). The RN Graduates had either moderate or strong mean relational coordination scores for all other stakeholder groups. In contrast, the ENs reported weak relational coordination with pharmacists, doctors, allied health, well-being staff and family members and strong relational coordination with only ANUM/RNs and other ENs. None of the three participant groups reported strong relational coordination with the family members of residents.
| Participant group | Mean (SD) | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Family | Senior managers | ANUM/RN | EN | Well-being staff | Allied health | Pharmacist | Medical staff | ||||
| ANUM/RN (n = 4) | 3.56 (0.48) | 4.39 (0.63) | 4.66 (0.50) | 4.49 (0.54) | 4.01 (0.64) | 4.32 (0.64) | 4.18 (0.63) | 4.49 (0.52) | |||
| EN (n = 32) | 3.39 (0.70) | 3.74 (0.82) | 4.09 (0.73) | 4.24 (0.53) | 3.28 (0.96) | 3.24 (0.88) | 2.62 (0.85) | 2.97 (1.00) | |||
| RN Graduate (n = 4) | 3.93 (0.82) | 4.43 (0.56) | 4.84 (0.19) | 4.79 (0.43) | 4.43 (0.65) | 3.79 (1.24) | 3.54 (1.18) | 3.76 (1.10) | |||
| Total sample RC score (n = 41)a | 3.50 (0.69) | 3.86 (0.81) | 4.19 (0.73) | 4.31 (0.54) | 3.47 (0.97) | 3.38 (0.94) | 2.87 (0.99) | 3.20 (1.07) | |||
- Note: Scoring categories: Weak (<3.5), moderate (3.5–4.0), or strong (>4.0) (Gittell et al., 2015).
- Abbreviations: ANUM/RN, Associate Nurse Unit Manager/Registered Nurse; EN, Enroled Nurse; RC, relational coordination; RN Graduate, Registered Nurse Graduate.
- a One respondent did not specify their role so was only included in the total sample results.
3.5 Interview participant characteristics
Twenty-nine (n = 29) nurses representing 62% of the eligible staff population in the unit participated in an individual interview, and the majority (93%) were ENs. These participants had between 2 and 40 years of experience working in LTC (M = 13.03, SD = 8.25); between 6 months and 25 years in their current role (M = 7.92, SD = 6.03), and most (n = 22, 76%) were employed part time. In describing the interview findings, the term ‘nurses’ is used to refer to the sample collectively and more specific terms such as EN or RN are only used where differences were apparent between the two groups.
3.6 Major themes
Three major themes were identified related to how nurses perceived their empowerment and engagement at work, and the support required to promote nurses’ empowerment and engagement. To ensure the nurses’ confidentiality only the study identification number is provided after example verbatim quotes.
3.6.1 Empowered to care
In exploring empowerment, it was important to understand what this meant to the nurses and the impact of empowerment on their work. This theme captured the meaning of empowerment for these nurses and the importance of empowerment in their work, with a particular focus on autonomy and other factors that enabled them to feel empowered in their work.
Like it's not easy work, so, and I think nursing itself is rewarding. That's there. But to be recognised for what you do, I think it's important. (ID5)
Nurse empowerment is to feel valued at work, be listened to and to be creative as a team—your input is valued. (ID26)
Just to work and to look after the people. Whatever they need. I have to do for them to make happy [sic]. My role is just to be good quality of care, to look after them, comfort for them … [sic]. (ID15)
We are the ones who understand their situation as it is, their ground, the care recipients, their families because we're the ones interacting with them on day to day basis [sic]. So if we are allowed decision making, in some aspects of work here, definitely [we] would offer more care recipient-centred and appropriate [care]. (ID2)
We are all nurses here. With wide experience. As a team, we are able to sit down and discuss and strategise. If only our seniors [managers] could allow us to make some of the decisions, … I believe the morale of all the staff members, the team would strengthen them, it will boost the morale. It will enable more communication, feel that they have a voice. And you know what, if you have happy staff, you have happy care recipients. (ID2)
Just what gives us the ability to do certain tasks without having to have permission, as such. I—obviously, what's within our scope, but being able to go ahead and just do certain things without having to have the permission, like knowing—we know what we're doing and we know what's within our scope. But yeah, sometimes you get, oh, we want to do that, or, we need to oversee that, or—and sometimes it's like, okay, well I'll wait for you [RN] then. (ID9)
Even for the ENs they do the ADLs [activities of daily living], they interact more with them [residents]. So I would empower them by allowing them that autonomy for that immediate decision making. They actually have the picture more than us [RNs]. (ID2)
It's always been the Div 1 [Division 1 = RN] spoke to the pharmacist and the Div 1 spoke to the doctors. So for me, that's just the norm, but then when you see a lot of med [medication] changes and things happen like as someone on the floor, you start getting a little bit annoyed [sic]. It's like if we could talk to them [doctors] and explain why we want that or why it's not a good idea to take them off that [medication], then maybe they'd have a bit of a better understanding rather than just stopping something or changing something. (ID5)
Okay, yes, there's skill levels, but I think everyone should be listened to…sometimes I feel like because we're just ENs our say doesn't count. (ID20)
I will admit, if I've seen the podiatrist or the physio [physiotherapist], I will have a chat to them about someone …. Like, if they're about to assess someone, they'll come on the floor and ask us what we've been doing and how we've been managing their mobility or whatever. Then they'll go in and assess them and come out and go yeah, you guys are right. We'll go with that plan. (ID5)
I feel empowered when I see positive outcomes on shift. So if we follow the care plan and the care plan follows through I think, okay this works. So I know that this works and so I'll keep doing that. (ID8)
Suggestions were made about how to support nurses to feel empowered at work. These suggestions comprised ongoing support from management, education and training for nurses, as well as information for families about the nurses’ role in residents’ care. Many ENs sought having more input into the strategies for residents’ care, more decision-making power and more engagement with the multiprofessional team and family members.
3.6.2 Being present and focused
Just that you're here, 100 per cent here and that you're on the ball, you're doing your job, you know what's going on, you know—you've had your handover, you've asked all the questions, you know everything that's going on with your residents …. (ID9)
I just think before they [doctors] make changes, it would be ideal if maybe they could speak to us [ENs] and say, what kind of behaviour are you dealing with? Because that's the other thing as well, they come in the morning. The residents are all good in the morning because they're still waking up. They're perfect in the morning. Come three, four, five o'clock in the afternoon, they're all starting to go a bit funny. That's when they need to see the behaviours we're dealing with, because they don't—they just see them all sitting there. (ID9)
They also stressed the importance of informing the RN in charge if they do consult with other clinicians, such as physiotherapists.
Without engaging we can't do anything, especially this type of behaviour, the people with challenging behaviours. We have to talk to them. We have to be—we have to make bonding, the good therapeutic relationship with them, otherwise we can't do anything. (ID13)
…take care of them and look after them…engage with them and get to know them better … but then again, because we're so busy, it's really hard to sit one-on-one to do that. We would love to, but …. (ID25)
Well, it gives you also a bit of background on that person that you're looking after… When the families come, I'll always [sic]—what kind of music did they listen to? … what did they used to do during the day when they were just sitting in—because they'll just pace around. I'm like, is this normal behaviour? What did they used to sit down and do? I try and get information out of them so I can use the different strategies when they [residents] are behavioural [sic]. If I know that he used to like jigsaw puzzles, I've actually gone to the op-shop [opportunity, i.e., charity shop] and bought jigsaw puzzles and different things … (ID9)
… if they [family] wanted—they always have the power to report us. (ID17)
We were actually told that if we have any complex questions from family members, to direct it to the [RN] in-charge. (ID20)
A barrier to engaging with family members was that some family members did not visit residents often and, ‘you can't build the relationship if they're not [there]…’ (ID23).
You have to communicate really well. The communication is important to engage with them. If you see something, you don't say or you don't do anything, it won't work. If you see something, you have to talk to that person. If you see someone with something wrong, you have to talk to them, communicate well…Communication is important. (ID13)
I want them to ask as many questions as possible…Yeah, I'm like please ask … so there is an understanding. There'll be communication there. There'll be a link … So they know what's going on. (ID17)
3.6.3 Support to care
You need to be [dedicated] as a nurse. I don't think you'd be in the right job if you weren't dedicated to do it and to do it properly … once you're here, you're here, you are 100 per cent switched on. You have to be. (ID7)
Because we have to be like team. If we say team, we have to look after each other. We have to [sic] are you okay … support each other. Team work together …(ID15)
Some expressed they were close to other staff and their colleagues were ‘…like family…’ to them and that staff also cared for the residents ‘…like they are their own family like they were family’.
Yeah, definitely. In a positive way. Some of them, I suppose, can speak languages that I can't, with certain care recipients. You know … I think it's really good. (ID11)
This diversity was also described as beneficial for staff morale for example there would be times such as New Year's Eve, when staff would bring in their cultural foods to share with other staff.
…More lifestyle staff and more trained staff in dementia, Alzheimer's and as in the lifestyle staff because I don't think the lifestyle staff fully comprehend the patient's [sic] disease and diagnosis to make activities suitable for them … (ID5)
…more education on the way we approach behaviours, because a lot of people feel scared approaching patients, especially when they're kicking at you or hitting at you or spitting at you or stuff like that. There's different ways we could be dealing with that. More education on that. (ID22)
So it's more—also we all need to learn more things about the medications. It's always—the new things keep coming out so we always need to learn. (ID10)
I was checking in on them and saying, how are you going and just giving them a bit of space to work independently and under supervision but also acknowledging how they are feeling, at the same time if something does happen. It helps them, it helps change the culture …(ID8)
Correct, because from out coming from the uni [sic], they learn a lot of new things. So that's a theoretical part, they're highly knowledgeable. It's come to the practical, it's good for us. (ID3)
4 DISCUSSION
To our knowledge, this is the first study to explore work engagement, psychological empowerment and relational coordination among nurses in LTC. The survey findings indicated these nurses had high psychological empowerment and work engagement. They were very dedicated to their work, caring for residents and perceived their work to be meaningful and important. The strength of relational coordination varied based on the nurse group (i.e., RNs or ENs), and the extent of their interaction with different stakeholder groups. The ENs reported weaker relational coordination with others in the multiprofessional team compared with RNs and the interview findings provided contextual information for this finding, particularly in relation to the way in which communication between the multiprofessional team in the unit was structured. The interview findings also suggested this communication structure had implications for ENs’ empowerment and engagement that contrasted with the positive survey findings.
The nurses’ high scores across the four domains of psychological empowerment are consistent with previous research in LTC, although participants in other studies were personal care workers/nurses’ aides/nursing assistants (Barry et al., 2019; Berridge et al., 2018; Cready et al., 2008; Kostiwa & Meeks, 2009). Empowerment of LTC staff has been shown to improve the experiences of both staff and residents (Barry et al., 2019). Although there is a paucity of research regarding empowerment among nurses in LTC, a positive relationship between empowerment and job satisfaction has been identified among nurses in the acute hospital setting, with learning opportunities and access to support strongly associated with job satisfaction (Cicolini et al., 2014). The interviews revealed that empowerment for these nurses encompassed their ability to care for residents and was associated with the sense of achievement they experienced in providing high-quality care. Participants tended to focus on elements of the workplace that assisted them to provide quality care such as feeling supported and valued, having autonomy, being encouraged to voice their opinions and contribute to decision-making about resident care. While the survey measured psychological empowerment, the way in which nurses described empowerment appeared more consistent with aspects of structural empowerment (Saleh et al., 2022).
The interview findings highlighted structural factors within the LTC unit that hindered empowerment. In particular, the ENs described a lack of autonomy in their role specifically through their lack of opportunities to engage with the multiprofessional care team and family members. The relational coordination scores varied between groups and revealed clear differences in how the ENs and RNs related to other stakeholders. In LTC, residents’ multiple care needs often require care coordination involving a multiprofessional team (Tingvold & Munkejord, 2021). As such, communication and positive relationships among the team are essential for the quality of healthcare delivery (Rosen et al., 2011). Additionally, communication was identified as a key enabler of nurse engagement in the current study.
Care workers having some freedom in decision-making has been identified as important in providing quality care (Meagher & Szebehely, 2013). Autonomy and involvement in decision-making emerged as central to empowerment in the current study and, given the ENs’ role as the primary care providers who were most familiar with the residents, both RNs and ENs highlighted the need for ENs to have autonomy in their role. They noted that decision-making was not exclusively the domain of RNs. Nevertheless, an unspoken rule of communication in the unit involved unidirectional communication from the EN, to the RN and subsequently to the doctor, of residents’ symptoms, goals of care, daily activities, implementation of treatment and evaluation of treatment. This unspoken rule may have contributed to ENs’ reduced autonomy and involvement in decision-making, and diminished opportunities for aged care workers of different disciplines learning from each other through interactions and developing respectful and cooperative collaboration. Furthermore, if ENs were included in multidisciplinary meetings, their insights could have been shared with residents to enhance social connectedness and support health and well-being (Hedman et al., 2019).
Of note, both the ENs and RNs reported low scores for the impact dimension of psychological empowerment suggesting that they did not perceive themselves as able to influence or contribute to the decision-making process or strategic operations of the unit. Low-impact scores have previously been reported by nurses from critical care settings in hospital (Ranjbar & Gorji, 2018; Redley et al., 2021). It is possible that this perceived lack of influence and involvement in decision-making may be associated with the lower scores on the vigour dimension of the work engagement scale, which relates to willingness to invest effort in one's work and persistence in the face of difficulty.
Neither the RNs nor ENs reported strong relational coordination with family members. The interview findings indicated clear delineation between RNs and ENs with regard to engaging with resident families, and some ENs feeling uncomfortable with this process, particularly if they felt intimidated by family members or were concerned that the family might report them if they were unsatisfied with the care. This view is consistent with early studies of family involvement in LTC where family members were sometimes perceived as interfering and critical of the staff and the environment (Gaugler, 2005). Indeed, Hovenga et al. (2022) identified that family members are sometimes reluctant to communicate their concerns with staff in case they are regarded as being critical and they perceive that staff are not open to feedback. Nonetheless, nurses in the current study acknowledged the importance of open communication with resident family members and suggested that this facilitated work engagement for staff and would provide greater peace of mind for families. It is possible that nurses’ expression of fear or reluctance to interact with family members related to their focus on direct care activities with residents, especially in situations relating to ENs’ work practices. Previous work has shown nurses working in nondirect roles perceived families to be less burdensome, which helped to facilitate involvement with family as a conversational partner (Cranley et al., 2022). Furthermore, the cultural diversity of nurses in the unit may have contributed to challenges in communication and experiences of marginalisation from the perspectives of nurses and families, as demonstrated in past work (Puurveen et al., 2018). This aspect could be explored in future research. Staff and family members in LTC have acknowledged the importance of developing and maintaining a good relationship to improve residents’ care (Bauer et al., 2014), and family members have a desire to work in partnership with staff so they can support staff and be included in decisions about the resident's care (Hutchinson et al., 2017). The level of psychological empowerment has been shown to predict the level of work engagement (Meng & Sun, 2019). The high overall work engagement score and particularly for the dimension dedication, indicated that the nurses had high regard for their work, were very dedicated and had high value in what they do. Their dedication to the work was confirmed in the interviews where the nurses’ discussed their commitment to providing care and making a difference to the residents’ lives. Engagement for these nurses was described as being present and focused. Marshall et al. (2020) identified that LTC staff go ‘above and beyond’ to care for residents and this is connected to the relationship and rapport that develops between staff and residents.
In LTC settings, nurses have a pivotal role in supporting residents’ care and well-being needs which includes accurate, appropriate and timely engagement with healthcare and well-being professionals and family members. The findings in this study suggest that it is important to find ways to ensure that all who provide care to people in LTC perceive that they are part of the whole care team. Nurses’ suggestions to help achieve this included: inviting all staff to participate in discussions about resident care, creating opportunities to maximise communication and collaboration among the multiprofessional care team, strengthening the partnerships between staff and resident family members so that all stakeholders feel comfortable and confident to share ideas and raise concerns, and providing staff access to ongoing education and professional development that is relevant and tailored to their learning needs.
4.1 Strengths and limitations
This study adds to the limited body of research on staff empowerment, engagement and relational coordination in LTC, and specifically the focus on nurses in this setting. Key strengths include the high response rate for the survey and interviews. There are limitations to acknowledge. The study setting was a single unit within one LTC setting so the results may not be applicable across all types of LTC settings. The relatively small sample size, including a small number of RNs precluded us from exploring any differences that may have existed between the EN and RN groups in this sample and the different staff culture and language groups. The impact of staff empowerment, engagement and relational coordination on resident outcomes was not examined in this study.
4.2 Conclusion
Our study examined nurses’ self-reported work engagement, empowerment and relational coordination in LTC. Australia's aged care sector continues to face significant challenges related to policy reforms, service delivery and care recipients’ needs and expectations. Nurses in LTC globally have a continually evolving role to support the complex care needs of residents within ongoing sector reforms and challenges. Nurses have a pivotal role in supporting residents’ care and well-being needs which includes accurate, appropriate and timely engagement with the multiprofessional team and family members. In this study, how nurses related and communicated with other stakeholders was variable. Our study highlights the importance of all care staff in LTC having the right supports and opportunities to facilitate their contribution with the multiprofessional care team.
A key implication for practice is that all staff in LTC need to be supported to make meaningful contributions and feel part of the multiprofessional care team. Our research suggests that nurses need opportunities to effectively participate in discussions about resident care, therefore LTC providers must have clear policies to promote these opportunities. These policies must incorporate access to ongoing education and professional development tailored and related to nurses’ work, including communication and language support to ensure accurate, appropriate and timely communication for effective engagement with families and the multiprofessional team. Regular support is needed to enable nurses to feel empowered, foster communication and relationships among all stakeholders, and facilitate work engagement.
AUTHOR CONTRIBUTIONS
Helen Rawson, Sarah Davies, Cherene Ockerby, Ruby Pipson, Ruth Peters, Elizabeth Manias and Bernice Redley: Conceptualisation and methodology. Helen Rawson: Led data collection. Helen Rawson, Sarah Davies, Cherene Ockerby, Ruby Pipson, Ruth Peters and Bernice Redley: Data analysis. Helen Rawson: Original draft manuscript. Helen Rawson, Sarah Davies, Cherene Ockerby, Ruby Pipson, Ruth Peters, Elizabeth Manias and Bernice Redley: Reviewing and revising manuscript.
ACKNOWLEDGEMENTS
The authors are grateful to the nurses who generously volunteered their time and engagement to participate in this research. The authors thank Shaluni Tissera for assistance with data collection and Dr Ruth Williams for assistance with interview data analysis. This study was funded with a Patient Safety & Quality Care Project Grant from the Australasian Institute of Clinical Governance. Open access publishing facilitated by Monash University, as part of the Wiley - Monash University agreement via the Council of Australian University Librarians.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.
Open Research
DATA AVAILABILITY STATEMENT
The data are not publicly available due to privacy or ethical restrictions.
