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Advances in Social Sciences Research Journal – Vol.7, No.10
Publication Date: October 25, 2020
DOI:10.14738/assrj.710.9291.
Herold-Majumdar, A., Marijic, P., & Stemmer, R. (2020). Organizational Culture Empowering Nurses And Residents In Nursing Homes.
Advances in Social Sciences Research Journal, 7(10) 590-611.
Organizational Culture Empowering Nurses And Residents In
Nursing Homes
Astrid Herold-Majumdar
Munich University of Applied Sciences, Faculty of Applied Social Sciences
Am Stadtpark München, Germany
Pavo Marijic
Helmholtz Center Munich, Institute of Health Economics
Health Care Management, Germany
Renate Stemmer
Catholic University of Applied Sciences Mainz,
Faculty of Healthcare and Nursing, Saarstraße, Mainz, Germany
ABSTRACT
Purpose. If nurses should respect resident ́s autonomy, nurses
themselves must experience empowerment and respect for their own
autonomy in the work environment. The purpose of this study is to get
a deeper understanding of nurses’ perception of their own
empowerment in the organization’s culture during an intervention
program for strengthening autonomy. Design/methodology/approach.
Guided semi-structured interviews and moderated group discussions
were conducted before and after the intervention. A structured and
evaluative content analysis of the text material were performed.
Findings. In total 73 nurses and nurse aids working at frontline with the
residents were voluntarily included into the study. New categories for
nurses’ perceived empowerment and organizational culture could be
derived from the text material. Originality/value. The study’s results
deliver a theoretical model with a sophisticated system of categories for
organizational culture as perceived by nurses that can be used for
further qualitative and quantitative research and for a sustainable
organization development.
Key words: organizational culture, empowerment, nurse, nursing home,
autonomy
INTRODUCTION
The possibility of making choices (self-determination and decision making) and being able to
implement these choices into daily (work) life practice (executional autonomy) are human rights
and prerequisites for a good life (Bölenius et al., 2019; Bollig et al. 2016; Davies et al., 1997). Nurses
are obligated to respect this human right and to realize it with individuals in need of nursing care
unrestricted by considerations of age, color, creed, culture, disability or illness, gender, sexual
orientation, nationality, politics, race or social status (The ICN Code of Ethics for Nurses, ICN, 2012).
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Herold-Majumdar, A., Marijic, P., & Stemmer, R. (2020). Organizational Culture Empowering Nurses And Residents In Nursing Homes. Advances in Social
Sciences Research Journal, 7(10) 590-611.
Autonomy and quality of life are critical outcome factors in long-term care (Edvardsson et al. 2019;
Grant, 2008; Koren, 2010; Cohen-Mansfield et al., 2000). In this context, autonomy is understood
from a relational (Sherwin and Winsby, 2011) and social constructive (Moebius and Quadflieg,
2011) perspective as something that must be realized in every situation of interaction. If nurses
respect patient ́s autonomy, nurses themselves must experience respect for their own autonomy in
the work environment. Perceived job control can make nurses feel empowered and make them less
vulnerable to the adverse effects of high job demands (Kim et al. 2018; Schmidt and Diestel, 2011).
Therefore, an adequate range of self-determination in the job context must be implemented into
nursing care institutions.
The sustainable implementation of an empowering job environment with high degrees of job
control need an organizational culture that supports members’ self-determination. Less is known
about how nurses’ perceive organization’s culture concerning their empowerment in long-term
elderly care facilities. A theoretical framework with nurse-specific categories is needed to support
organizational research in this specific field of work environments.
The purpose of this study was to understand what are the main categories of an organization’s
culture that are important for nurses to develop their autonomy in work-life. From an
organizational research perspective and with an emic approach we tried to get a deeper insight into
nurses’ perception of the organizational culture change process during an intervention program for
strengthening autonomy in the special field of elderly long-term care.
WHAT WE KNOW ABOUT NURSES’ EMPOWERMENT
Staff shortage and high turnover rates are challenges for organizations in long-term care. These
challenges can be handled by organizational learning and culture change processes. Bjørk and
colleagues (2007) identified autonomy as a critical job satisfaction factor other than interaction
followed by pay. Nurses ́ perceived autonomy is a predictor of nurses ́ work satisfaction, intention
to leave (Nasabi and Bastani 2018; Rai, 2013; Engström et al., 2011) and quality of work life
(McGillis Hall et al., 2006). If autonomy can retain nurses organizations must implement structures
and cultures that increase nurses’ feeling of self- determination and empowerment. Lived
participation and a culture that empowers nurses can improve nurses’ resilience against high job
demands (Kim et al. 2018; Schmidt and Diestel, 2011).
Empowerment and high job control are strongly related to job satisfaction (Saber, 2014),
organizational commitment, and turnover intentions (Lautizi et al., 2009; Wendsche et al., 2016;
Zurmehly, 2008). Autonomy is furthermore a prerequisite for nurses ́ self-efficacy. Without the
feeling of being able to decide and to implement things at least on the operative level, nurses cannot
put their own decisions or the shared-decisions with the residents into clinical practice.
Decentralized decision making is necessary for a flexible reaction to a resident ́s needs and wishes
(Ramaswamy and Gouillart, 2010) what is vice versa the prerequisite for residents’ autonomy.
Furthermore, empowering frontline staff working directly with clients is correlated with effective
organizational learning (Mishra and Bhaskar, 2010; Joo and Shim, 2010) and, consequently, with
improved outcomes on residents’ side (Barry et al., 2005). Hence, nurses ́ autonomy and residents’
autonomy strongly interact.
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There is increasing evidence that nurses’ empowerment lead to better outcomes on residents’ side
but less is known about how nurses perceive their empowerment in an organization’s culture
environment. Råholm and colleagues (2017) show in their systematic review the four main themes
in qualitative research about organizational culture in nursing homes: (a) the organizational culture
reflecting an inner commitment to care, (b) an organizational culture reflecting distress and
insecurity, (c) the organizational culture reflecting value conflicts, and (d) the impact of
organization of care and leadership on the organizational culture (Råholm et al., 2017: 87).
The focus on culture aspects that are influencing nurses’ perception of their empowerment as an
important prerequisite for residents’ empowerment (culture change movement of the Omnibus
Budget Reconciliation Act, OBRA 1987, Kelly, 1989) is missing. Balancing effective care routines
within an organization that is trimmed to efficiency and core values of the nursing profession’s
ethics code (ICN, 2012) is a key leadership task (Råholm et al., 2017: 87). Empowering nurses and
giving them a decision-making scope is playing a key role here. Hence we need a deeper
understanding how nurses themselves perceive their empowerment in an organization’s culture for
being able to develop this culture to a more participating and strengthening culture for all members
of the organization.
NURSES’ PERCEPTION OF THEIR OWN EMPOWERMENT AND THE ORGANIZATIONAL
CULTURE
Theoretical background and sensitive concepts
Organizational culture is understood in this context as a social control system (O’Reilly and
Chatman, 1996), as a phenomenon that is socially constructed with several levels as defined by
Edgar Schein (Schein and Schein 2018). Organizational culture is a stabilizing and simultaneously a
dynamic construct. As a system of group-shared norms and values that are guiding attitudes and
behaviors (social control system) culture can instill a sense of security and stability for the group
members. Culture itself has also a dynamic aspect in the sense of learning initiated by new
challenges that must be handled to survive as a group or an organization.
From this point of view organizational culture is strongly connected to organizational learning
(Schein, 1993). Schein’s three level model of organizational culture (Schein, 1984) try to explain the
phenomenon as something that is visible and touchable (artefacts) but also intangible. The
philosophical basic beliefs that are underlying the values and norms are generally not conscious.
Whereas the norms and values are often explicitly stated in the mission statement of organizations.
They can even appear physically in artefacts. If the appreciation of frontline worker’s services is a
core value of an organization the management may express this by gestures such as installing coffee
machines where staff members can have coffee for free. These coffee mashines can stand for a
frontline staff-oriented organization and symbolize organization’s culture as an artefact.
Organizational culture can empower or depersonalize its members.
Empowerment mean participating in organizational decisions to an individual and an adequate
degree. Psychologically empowered nurses perceive self-efficacy. Self-efficacy means working on
solutions to professional problems and experiencing that these solutions can be implemented into
clinical practice and change clinical practice.
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Herold-Majumdar, A., Marijic, P., & Stemmer, R. (2020). Organizational Culture Empowering Nurses And Residents In Nursing Homes. Advances in Social
Sciences Research Journal, 7(10) 590-611.
For a sustainable implementation of nurses ́ autonomy and psychological empowerment an
organizational learning and cultural change process must occur. The intervention program of this
study was implemented to initiate such an organizational learning process. A learning organization
requires a culture that enables and encourages its members to learn (Murray and Chapman, 2003:
275); in this case, this means learning how to realize autonomy in the daily life and work practice
of a residential home. Organizational learning is an individual process for its members and a group
process supported by organizational structures, organizational culture and by processes (Murray
and Chapman, 2003). Because of the study ́s intervention program, a single-loop learning (Argyris
and Schön, 2018: 35) process was initiated. Organizational learning and organizational culture
change processes are specific and are dependent on the organization’s living world, that is to say
members’ perception of the organization as a living and working environment.
Nurses’ living world and work environment in long-term elderly care facilities – the research
field
Long-term elderly care facilities are special work environments with specific work load and
challenges for frontline staff working directly with persons of advanced age and in the need of
nursing care. <<The nature of long-term care>> (Kane and Kane, 1988: 133) compared to acute
care settings is a longer time horizon that offers on the one hand an opportunity for quality
assurance and deeper relationships between the nurse and the person in the need of nursing care.
On the other hand frontline staff has a high psychological distress because they share everyday life
for a whole stage in life with persons with severe physical and cognitive impairments. Nurses are
often important related persons. In some cases they are the only contact partners for residents.
Balancing professional distance and personal closeness is a challenge. Realizing residents’ self- determination and quality of life in everyday life as important outcomes in long-term care (LCT) is
a high job demand for nurses.
Nursing homes are not only places of medical treatment and professional nursing care, nursing
homes are primarily places where people with long-term care need find their center of life and a
place to live. Realizing privacy, one ́s own life style, the feeling of being at home and of being safe
are in the forehold whereas medical treatment and nursing assistance are in the background.
Nursing in LTC is normally less specialized and workload is high. Sometimes there is a big range of
the specification of professional tasks, from support with daily living to the management of home
mechanical ventilation. In Germany the staff in nursing homes is highly skill-grade-mixed. There are
geriatric nurses and general nurses with a three years course, nurse aids with a one-year course
and everyday companions without any qualification in the medical field. Nurses with a Bachelor ́s
degree are very rare in those teams. Historically nursing care in nursing homes is regarded as less
qualified than in hospitals. Relatives and family caregivers play a major role not only in the
homecare setting but also in nursing homes. Family members often manage the nursing care at
home over a long period before they decide to bring their dependent relative into a nursing home.
The decision is often associated with feelings of guilt that can be conveyed onto the nurses. Family
caregivers feel as experts for the care situation of their relative in the need of nursing care and want
to give their expertise to the nurses.
Additionally there are high demands for nursing care in long-term care facilities from external
quality control authorities. Home supervisory authorities, nursing care and health insurances who
are paying for the services are inspecting regularly quality of nursing care in LTC facilities. External
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quality control teams stay only for one or two days in the nursing home and meet residents for a
few minutes to get an impression of their health status and of nursing care quality. Care
arrangements and residents’ nursing care need are often highly complex so it cannot be judged
within a short time and on the basis of few information. Nurses feel their services frequently judged
false and not valued by these authorities. These are some reasons why nurses in LTC facilities are
at high risk of decreased autonomy.
For better understand how nurses themselves perceive their autonomy concerning professional
decisions in their work life and how they experience organizational culture during an organizational
change process with the aim to improve autonomy a qualitative research approach was chosen. The
study was conducted in four nursing homes from February 2016 to February 2019 during an
intervention program comprised nurses’ training in autonomy and the introduction of nurses’ peer
group supervision (Benshoff and Paisley, 1996). In the peer-group supervision meetings nurses and
nurse aides should learn about solving professional problems at the service encounter by
themselves to strengthen their professional autonomy and their feeling of self-efficacy. Peer group
supervision follows a systematic six-step structure and has pre-defined roles (Tietze, 2010).
The nurses should have met a minimum of once per week to discuss professional problems. The
discussions were moderated, and the results were documented. Support was provided by two
research associates to organize and moderate the peer group supervision meetings during the
whole study period. One research associate was a male nurse specialized in elderly care and held a
Master of Nursing Science. The other research associate was a male nurse for general care with a
Master of Public Health. Both research associates were not staff members of the nursing homes
participating in the study. On-going and ex-post evaluation was conducted during the intervention
phase.
Sampling strategy
The participating long-term care facilities voluntarily applied to the study after being asked by the
project leader. An ethical clearing of the study design was ex-ante given by the German Society of
Nursing Science (application number16-005a). Residents were not directly affected by the study.
Nurses and nurse aids were informed by written information sheets and by information events and
were asked to participate in the study. They took part in the study voluntarily and could leave the
study and interviewing process at any time.
Nursing homes of diverse sizes (e.g., number of beds), diverse sponsorships (two private, for-profit
organizations and two not-for-profit organizations), and diverse locations (rural and urban) and of
two German federal states (Bavaria, Rheinland-Pfalz) were selected for the study (heterogeneous
sample). These diverse structures of the participating organizations should help to obtain deeper
insight into diverse organizational cultures influenced by the environmental cultures (e.g., rural and
urban environment), the size and sponsorship. Wendsche and colleagues (2016) showed that the
intention to leave the job, job demands, and job control vary in for-profit and nonprofit nursing
homes and home care services. Hence, the sample was built heterogeneously concerning some
organizational characteristics but homogeneously concerning the setting (long-term elderly care),
population (individuals with long-term care needs and of advanced age), and the participants
(nurses and nurse aides). Inclusion criteria were predefined for the sampling of the participants.
Nurses (general and geriatric nurses with a minimum 3-year vocational training program) and
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Herold-Majumdar, A., Marijic, P., & Stemmer, R. (2020). Organizational Culture Empowering Nurses And Residents In Nursing Homes. Advances in Social
Sciences Research Journal, 7(10) 590-611.
nurse aids (with a one year training program) had to be employed in the nursing home for a
minimum of half a year to have an insightful perspective of the organization’s culture.
Participants from diverse units of the participating nursing homes were included in the study. The
total number of n= 73 nurses and nurse aids (Nt0= 137 and Nt1= 146 nursing staff in total)
participating in the study resulted from a three-step process following the hermeneutic circle: 1.
information and akquision of participants who voluntarily took part in the study 2. single interviews
and group discussions with the help of a theory-based, pretested guideline at t0 3. revision of the
guideline for a second round at t1 of interviewing and group discussions on the basis of the results
of the first data collection at t0. A third round was planned but not realized because of the text
material at t1 did not show new aspects of nurses’ perception of organizational culture. Data
saturation could be hypothized at this stage of the study.
Methods used
Organizational change processes such as increasing nurses’ work autonomy by particular
interventions are long-ranging processes leading as mediators to quantitatively measurable
outcomes. Sustainable organizational changing processes are accompanied by the transition of an
organization ́s culture and by organizational learning. We posit that an explorative and
interpretative approach is appropriate to improve the understanding of how nurses experience this
organizational culture change process and what the specific phenomena of organizational culture
concerning nurses’ self-determination in nursing homes are. The primacy of the raw data from the
field in the analytical process of a qualitative approach guarantees a consequent view from an
organization member ́s perspective.
With this emic perspective, a deeper understanding of what organization culture means to its
members ́ autonomy in long-term care facilities can be gained. A phenomenological approach is
required to determine the specific and phenomenological characteristics of a residential home ́s
culture and of nurses ́ perception of their empowerment.
Guided, semi-structured interviews and moderated group discussions were conducted before (to)
and after the intervention (t1). The guidelines and planning of the interviews and group discussions
were pre-tested. Interviews and group discussions in the main study were audiotaped, were
transcribed verbatim, and a protocol was written during the group discussions. Participants ́
sociodemographic data was collected after the interview and after the group discussion.
All audiotaped interviews and focus group discussions were transcribed verbatim by hand by an
external typing office using VLC Media player and considering predefined transcription rules.
Nurses and nurse aides with a migration background and fewer language skills in German
participated in the study. Their original formulations of the answers in the interview and of the
contributions to the focus group discussion were transcribed without smoothing the text. Dialect
was not eliminated because the in-depth meaning of words in the original dialect cannot be
substituted by standard language.
After the transcription of the audiotaped interviews, a content analysis was conducted with a
deductive–inductive approach by following Mayring ́s (2016) qualitative content analysis with a
computer-based (MAXQDA Plus 12©, Verbi Software, 2016) structuring and evaluating (scaled
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categories) approach (Kuckartz, 2014). The theory-based, sensitizing concepts were used to
deductively structure the text material. Simultaneously, an open approach to work with the original
text material was conducted. Subcategories were inductively gained from the text material that
could not have been associated with the deductive categories. These setting-specific categories
allowed a phenomenological and deepened description of nurses ́ perception of organizational
culture and of their own empowerment. A sophisticated category scheme with clear coding rules
for each category and exemplary key quotes was developed within a multistep consensus process
between three coders. The coding tree can be reproduced in the code theory models (fig. 4 and fig.
5). For the analysis of the focus group discussions, the same category system of the single interviews
was used but without the evaluative categories because no group consensus about the evaluation
level could be assumed.
Hermeneutic Circle
The hermeneutic circle was realized in this study by first of all structuring the interview and focus
group guidelines on the basis of the underlying theory and sensitizing concepts (deductive
approach) shown under chapter 3.1. The first draft of the category scheme was also built by these
sensitizing concepts. With an open approach during the content analysis of the text material, more
detailed subcategories were created inductively from the text material. In a second and third round
of material analysis these inductive subcategories were used. The inductively built categories and
their wording are very close to participants’ living world and perspective as the key quotes show.
reflexivity
All coders were nurses, one coder was female, a nurse, and an undergraduate student in nursing
science. The second coder was male nurse, and held a Bachelor ́s in Nursing Science and a Master’s
degree of Public Health. Both coders had less experience in long-term elderly care. The third coder
was a female nurse, a senior lecturer in nursing science and the project leader. She had more than
20 years of experience in long-term care of aged individuals in nursing homes and in-home care
settings as a nurse, head nurse, an auditor, and an external consultant. The project leader did not
collect data in the field but supervised the consensus conferences during the coding process. Before
rating the whole text material, the inter-coder reliability was calculated and reached 93% after a
multistage consensus process.
Implicit and explicit assumptions were reflected by the coder-team during the long-ranging
consensus process. These reflections and memos during the coding process helped to control the
transmission of the coder ́s own experiences onto the text material of the field. Each coded sequence
was weighted concerning the coder ́s estimate regarding how strongly the text passage matched the
category as it was predefined. The weights were useful for choosing adequate and convincing
quotes for the explanation and validation of the categories.
DATA SET
Characteristics of the participants
Characteristics of the participants of the single interviews
At baseline (t0), 13 individual interviews (with five nurse aides and eight nurses out of N = 62 nurses
and N = 75 nurse aides) were conducted. Eighteen months after the intervention (t1), 12 individual
interviews (with five nurse aides and seven nurses out of N = 76 nurses and N = 70 nurse aides)
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Herold-Majumdar, A., Marijic, P., & Stemmer, R. (2020). Organizational Culture Empowering Nurses And Residents In Nursing Homes. Advances in Social
Sciences Research Journal, 7(10) 590-611.
were carry out. The mean duration of the individual interviews was 42 minutes. Participants ́
characteristics at t0 and t1 are shown in table 1.
Table 1: Individual interview participants ́ characteristics at t0 and t1
Total T0 T1
Absolute number of participants N=25 N=13 N=12
Age
Mean (sd) 41,2 (11,5) 44,0 (12,7) 38,4 (10,1)
Median 38,5 49,0 34,5
Min - max (range) 22 - 61 22 - 61 26 - 53
Gender
Male (%) 5 (20,0) 2 (15,4) 3 (25,0)
Female (%) 20 (80,0) 11 (84,6) 9 (75,0)
Qualification
(geriatric or general) nurse (%) 15 (60,0) 8 (61,5) 7 (58,3)
Nurse aid (%) 10 (40,0) 5 (38,5) 5 (41,7)
Working hours
Full-time (%) 20 (80,0) 11 (84,6) 9 (75,0)
Part-time (%) 3 (12,0) 2 (15,4) 1 (8,3)
Period of employment (in months)
Mean (sd) 71,0 (54,2) 75,9 (56,0) 64,3 (54,1)
Median 60,0 60,0 50,5
Min - max (range) 7 - 216 14 - 216 7 - 113
Employment status
Temporary worker (%) 0 (0,0) 0 (0,0) 0 (0,0)
Staff member (%) 25 (100,0) 13 (100,0) 12 (100,0)
Characteristics of the participants in the group discussions
In total, n = 28 nurses and nurse aides joined four group discussions at baseline (t0). Mean number
of participants in each group was 7.0. Participants ́ median age was 35 years. Mean duration of the
group discussion was 65 minutes. Mean period of employment was 34.3 months (approximately 3
years). Eighteen months after the intervention (t1), n = 20 nurses and nurse aides joined the four
group discussions. Mean number of participants in each group was 6.7. Participants ́ median age
was 42 years. Mean period of employment was 91.5 months (about 7.6 years). Concerning the
median age and the mean period of employment, the sample from the focus group discussions is not
comparable between t0 and t1. Due to fluctuation, we could not include the same individuals from
the baseline sample in the study at t1. The basic assumption of the qualitative study was that
organizational learning and cultural change processes are systemic processes that can be
understood as group processes independently from an individual ́s perspective.
Text material and codings
The analogous English translation by the first author and not the original German text of the key
quotes is cited. Insertions marked by squared brackets are made by the author. In brackets behind
the quote, it is indicated if the quote is a citation from a single interview “I” or from a group
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discussion “GD,” and it is identified if the quote is from t0 (baseline) or from t1 (after the
intervention) material. Due to anonymization, the abbreviations of the institutions and the codes of
the participants are not shown. Results are shown from the structured content analysis and from
the evaluative content analysis of the scaled categories. The absolute number of encodings is
mentioned to provide an impression of how intensively topics were discussed in the interviews and
group discussions.
Table 2 shows the categories inductively gained from the text material before (t0) and after (t1) the
intervention. The categories of nurses ́ perception of organizational culture show a greater variety
and new aspects after the intervention (t1).
Tab. 2 Inductively created categories of nurses ́ perception of organizational culture before (t0) and
after (t1) the intervention
Categories of organizational culture at t0 Categories of organizational culture at t1
no confidential handling of information in
the team, speaking behind another ́s back
constructive, professional and objective atmosphere
contructive solution of conflicts by talking each other
high staff turnover and bad working
atmosphere
staff ́s problems and concerns are solved proactively
flexible shift planning and scheduling
inflexible structure of the organization no consistent handling of conflicts
bureaucratic structures memos for the schedule without brakes
self-centredness of the wards case discussions of new, incoming residents are important
no consistent handling of conflicts no hierarchical differences between nurses and nurse aids
continuous coming and going of staff
members and residents
solution-oriented working
positive feedback and praise
frontline staff participates in operative decisions but not in
strategic decisions
clearly structured daily routine
staff is protected by the leaders for example against violent
colleagues or complaining family caregivers
gossiping
new staff members must subordinate in the daily routine
and in the hierarchy
In the case of problems the hierarchical way is clear
colleagues care for each other and aware of work overload
feeling of being stucked, no change even the head nurse has
no influence on changing things
a hard core of staff members but also a high turn over
not being resentful
a friendly relationship among colleagues and even with
superiors and clearly defined limits
culture of handling mistakes: mistakes are discussed in the
shift handover. After that everything is done.
low willingness to help each other
pressure to justify material consumption
lack of adequate salary and working material – no matter
where you look, everywhere shortage
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Herold-Majumdar, A., Marijic, P., & Stemmer, R. (2020). Organizational Culture Empowering Nurses And Residents In Nursing Homes. Advances in Social
Sciences Research Journal, 7(10) 590-611.
Organizational learning promoting and hindering categories were gained from the text material at
t0 and t1. Subcategories of organizational culture gained inductively from t1 material show
additionally important principles of the peer group supervision concept compared with the baseline
(t0) material. The following key concepts indicate nurses ́ awareness of the principles of the peer
group supervision principles: “constructive and proactive problem solving,”
“the importance of case discussions before a resident moves into the home,” “no
hierarchical differences between nurses and nurse aides,” “solution-oriented working,”
and “colleagues are caring for each other and are aware of work overload.”
“Togetherness, uh, (1) that we discuss all the issues. That we, uh, enlighten the whole
situation between us, that we say, for example, The resident, what are we doing there?
Let's do it this way or otherwise.” (I_t1)
Participants ́ readiness to solve professional problems together with colleagues is clearly expressed
in this quote. The feeling of being able to solve problems is observed in the formulation “we clear up
the whole situation between ourselves.” The intention of the study intervention programme was to
strengthen the self-efficacy belief of nurses and caregivers through the self-determined solution of
professional problems.
Before and after the intervention, the reduction of the material also shows categories that are not
supporting a culture of nurses ́ empowerment: for example, “low willingness to help each other” and
“feeling of being stuck, no change even the head nurse has no influence on changing things.”
“Or to give away your own (3) wishes, so if I say that the ward should be (2) changed or
with uh (1) equipped differently, that we make changes, because I come for example not
far. (1) So I've learned the geronto specialist and then (1) you learn a lot or should you
implement many things, I was suggested, but then I come with a proposal, then it will be
rejected. (1) And I just cannot develop that way. So I'm already working here (3), yes,
roughly according to the guidelines. (1) So you cannot bring in much yourself, it's just a
lot (2) rejected or there's no time for it. [to implement new things].” (I_t0)
In this quote the participant describes an organizational structure that does not support an
organizational learning process concerning increasing autonomy. The nurse participated in a
further training program for gerontological psychiatric nursing and wants to contribute new ideas
and knowledge gained in this external training program into the residential home. But she/he
experiences the rejection of these new ideas. The nurse does not express any feeling of self-efficacy
concerning the implementation of new ideas. In this quote, a type of frustration about the refusal of
suggestions for improvements is expressed.
The quote does not mention if the suggestions for improvement were refused by colleagues or by
executives. An organization unable to integrate new knowledge or innovations of members who
completed an individual learning process is missing opportunities to develop and to initiate an
organization-wide learning process. Furthermore, the staff member who completes further training
and is motivated to improve service becomes frustrated and feels they have failed. Feelings that are
not supporting the perception of psychological empowerment.
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Nurses ́ perception of their psychological empowerment
In total n = 116 text sequences could be coded under the category “motivation and incentives” from
the text material of t0 and t1. “Feeling as a team and helping each other,” “getting objective and
personal feedback,” “having fun at work and humor,” “getting opportunities for learning and
maturing as qualified nurse,” “being taken seriously by peers and by the head of the nursing home,”
“experiencing care of the superior (e.g., the head nurse) and recognizing symptoms of excessive
work demand by the head,” and “having career opportunities” are critical, inductive categories of
motivation for the participants. “Varying work tasks” were perceived as motivating, as indicated in
the following quote:
”Because (1) every day is different (1), for the people who are old, not every day is the
same, which makes the job beautiful too, (1) because every day (2) something new
occurs with the residents. And, and (2) er, therefore, that's (2) quite interesting then
too." (I_t0)
The diversified tasks of a nurse in a long-term care facility seem to be an incentive for the
participants. An interesting job is motivating, and in this quote, the nurse expresses a preparedness
for the everyday challenges with the resident. In this sequence the nurse brings the characteristics
of the job together with the motivation and with psychological empowerment (a feeling of being
able to cope with the everyday challenges). Motivation is a crucial factor for nurses’ perceived
empowerment and for organizational learning.
The understanding of good teamwork is also a subcode of the category nurses ́ psychological
empowerment. Standing together in a skill-grade mixed team makes each team member feel
empowered and able to handle professional problems and challenges. Participants ́ understanding
of good teamwork (n = 88 encodings in total) is characterized by the following inductive categories:
“being empathetic” (n = 8 encodings), “willingness of working together and helping each other” (n =
62 encodings), “clear organizational structure and knowing who is responsible for” (n = 10
encodings) and “appreciation of lower qualified colleagues” (n = 25 encodings).
An example of the category “willingness to work together and help each other” contains the following
quote:
“It ́s giving and receiving. Thus, I do not only ask for something. If I see that somebody
[of the team] is exhausted or is walking with a limp or whatever, I tell him: come, sit
down, I am going to look after your residents [here, the residents who are in the group,
the colleague is responsible for, are meant]. Well, I cannot merely take [from the team],
and I must give as well. On the other hand, I cannot merely give [to the team].” (I_t0)
The “willingness of working together and helping each other” had n = 62 encodings the quantitatively
most-often coded category in the subcategory “understanding of good teamwork.” From the nurses ́
perspective the high workload and the challenges when working with mostly severe physically and
cognitively impaired residents can only be coped with when all colleagues work together. In this
sequence the nurse expresses the need for a balance between giving and receiving by the team
members.
No hierarchical differences and the “appreciation of lower qualified colleagues” seem to be
prerequisites to function as a team as the following quote shows:
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“The resident needs both of us. A nurse is not seen to be better than a nurse aide or a
nurse aide is not seen to be better than a nurse. We all have tasks. And we have to carry
out our tasks. Our goal is we want to be satisfied and their [residents ́] needs are, uh...(1)
what is the name? to be satisfied.” (GD_t0)
The nurse aid says in this quote that the common aim, namely, to be satisfied at work and to satisfy
residents’ needs, is realized in cooperative team work. To be able to achieve these aims, collegial
teamwork at eye level is necessary. Working together on the same level despite diverse
qualifications is another critical principle in the peer-group supervision concept of this study ́s
intervention program and let team members feel accepted and empowered.
To effectively implement solutions as a result of a peer-to-peer case discussion and to perceive high
self-efficacy, frontline staff requires a high degree of participation in organizational decisions,
especially at the operative level. If nurses experience no support in implementing solutions worked
out in peer-group supervision and case discussions, they become frustrated. Self-efficacy means
working on solutions to professional problems and experiencing that this solution can be
implemented into clinical practice. The text material showed that if the head nurse does not support
the implementation of the solutions worked out in peer group supervision, the frontline staff
members lose their motivation to work on solutions for professional problems by themselves. The
solution of professional problems itself is not satisfying. Frontline staff members wanted to
implement these solutions in everyday worklife.
Participation in organizational decisions (n = 7 textual encodings) is a critical aspect for nurses ́
empowerment. The following quote shows an example of nurses ́ perception of a high degree of
participation in operational decisions:
“When talking about software conversion or a daily routine that should be changed –
we decide together. This is discussed by the whole team. For example, a physician says
the resident should carry ATS [compression stockings] – that ́s also a change – then,
okay, we agree or we do not agree. Then, we are discussing, and we give feedback to the
physician. Here, we can participate in the decision.” (I_t0)
The evaluative qualitative analysis of the data shows participants ́ tendency for a higher willingness
to participate in operative decisions (fig. 1) related to the direct work with residents and family
members than to administrative and strategic decisions (fig.2)
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Fig. 1 Importance of participation in operative decisions from nurses ́ perspective rated by the
coder before (t0) and after (t1) the intervention, y-axis: percentage of all encodings in the category
The percentage of all encodings as a result of the scaled content analysis of the text material showed
that 65.4% of all encodings in this category were scaled in the subcategory “very important” at t0,
whereas the percentage was 83.4% at t1 (fig. 1). During the intervention program the importance
of participating in decisions directly affecting daily work with the resident seemed to increase at t1
from the nurses ́ perspective. The following quote is an example of a low degree of importance of
participating in administrative and strategic decisions:
“And everybody knows me here. But (1) we did not have any problems here in the
communication, sometimes that comes, but if you have a good er team leader, er (1)
team leader, then that's all that makes it all good between us and that makes everything
uh (2) neat, I have to say. I think everything works because she's [the team leader]
there.” (I_t0)
Fig. 2 importance of participating in administrative and strategic decisions from nurses ́
perspective rated by the coder before (t0) and after (t1) the intervention, y-axis: percentage of all
encodings in the category
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In the following quote the nurse expresses a high degree of the importance of participating in
strategic and administrative decisions, especially if the executive decides not to integrate new
knowledge into the organization:
“I [interviewer is asking]: "Uh-huh. (2) So you would definitely (laugh) like to work more
independently? B: Yes. I: Yes. B: For sure. (2) Or at least (1) that the wishes one has, um
(3) are taken into account more, (1) that there are (1) conversations with the nursing
home director or with the PDL [head nurse] or perhaps also with the company xy
leadership, that one wants to implement that and that and if the halt says it does not
work, I would like to have reasons for it. (1) Because then I would say to them, I do not
know why I (1) do this training if I cannot (4) implement [new things I ́ve learned in the
training]. (4) Then, it's [the certificate] just a piece of paper, after all, that I have (2) in
my hand (laughs)." (I_t0)
Nurses ́ psychological distress
If nurses suffer from psychological distress their perceived psychological empowerment decreases.
The “feeling of not being able to master the quantity of daily work,” “pressure from external control
authorities to hold resident ́s body weight,” “feeling of not being able to fulfill resident ́s demands
adequately,” and “feeling stressed when residents suffering from dementia are out of their daily rhythm
and forced to stay in closed wards” are categories of nurses ́ psychological distress gained from the
text material.
“B: If a colleague is taking sick leave that day we are under stress. I [interviewer]: Mhm. B: Yes, and
it is sometimes sad. Yes. Well, I have already mentioned I don ́t want to become old and live in a nursing
home. I: Mhm. B: Well, it is really sad. Yes. If nobody is coming [and helping you]. All alone. Yes?” (I_t1)
The “feeling of not being able to fulfill resident ́s demands adequately,” especially in the case of sick
leave of staff members, causes staff shortages and psychological distress. The nurse in this interview
reveals her high empathy for the resident`s situation if the resident is not helped adequately. The
nurse feels emotionally charged when being unable to fulfill a resident`s needs because of the lack
of time.
How do nurses perceive their autonomy?
The evaluative analysis of the scaled categories shows a tendency that nurses ́ perceived autonomy
on the job is higher after the intervention (fig. 3).
The following quote is an example of nurses ́ perceived low level of autonomy in everyday clinical
practice at t0:
"B: I am, I am very, I am very strong bound. I can (2) decide, okay, today we are five
employees, we can divide who cares who, but things have to be done." (I_t0)
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Fig. 3 nurses ́ perceived autonomy: percentage of all encodings in the category “perceived
autonomy” before (t0) and after intervention (t1)
Nurses ́ perception of being bound to the nursing and medical care plan and to the planned daily
routine is expressed in several sequences of the interviews and focus group discussions. Not being
able to react to a resident ́s daily state and a resident ́s daily wishes is experienced as a restriction.
If a resident refuses to perform her/his daily body hygiene or to drink the amount prescribed by
the doctor, nurses have a dilemma because external quality control authorities and family members
are expecting things to be executed in the manner in which they were planned and prescribed by
the physician. Nurses ́ understand they are advocates for the resident and must argue for a
resident ́s autonomous decision, especially if this decision is contrary to the nursing care plan and
to a family member ́s expectations concerning health care and a good quality of life.
The head nurse, as iterated by the participants, was under pressure, too. If a resident became
dehydrated because he/she refused to drink, the nurses perceived themselves to be under pressure
to argue regarding the quality control authorities and with family members. If the resident cannot
verbally express his or her perspective, for example, due to cognitive impairment, the nurses must
argue instead of the resident. The high pressure from outside can lead to the ignorance of a
resident ́s will:
“TB: Yes, all the time I have to say, "Please eat!" Because if they [the residents] lose
weight, we'll get into trouble." (GD_t0)
The following quote is an example of nurses ́ perceived high level of autonomy in everyday clinical
practice:
“B: In principle, the daily routine [of the ward] can be influenced. There, I can decide
how I plan my time, how I manage everything.” (I_t1)
In this sequence of the interview at t1 the nurse experienced independence in the management of
the daily routine on the ward. Many other quotes showed that nurses were autonomous in decisions
concerning daily routine. However, the moment this daily practice affected administrative and
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Sciences Research Journal, 7(10) 590-611.
strategic decisions and the moment the daily practice was contrary to the nursing care plan or to
the doctor ́s prescription, nurses’ and even residents’ autonomy seem to be clearly limited.
Code-theory models
The categories and sub-categories gained from the text material can be arranged clearly in code- theory models. Code-theory models can help to better understand complex concepts such as
organizational culture. They deliver a structure for further qualitative and quantitative research.
How organizational culture is perceived by their members depends on the various types of
organizations in the various fields of the socio-economic system. Theories about organizational
culture and how organizational culture is influencing member’s empowerment and self- determination on a meta-level must be concretized for each special field and branch. While an
assembly-line worker may feel empowered when processes are highly standardized nurses need
spaces for decision making with the resident in daily work life practice for experiencing themselves
self-determined.
Nurses ́ perception of the organizational culture
Deductive and inductive categories of the structured content analysis show a complex network of
nursing-home–specific characteristics of the organizational culture as perceived by the nurses (fig.
4).
Fig. 4 Code Theory Model: organizational culture with inductive subcategories meaningful for
nurses’ empowerment at t1, number of codings in brackets
Nurses’ perceptions of organizational culture aspects meaningful for their empowerment are
illustrated in fig. 4. Norms and values that are leading the nurses in their work environment were
kindness, following medical prescription, flexibility in shift planning, continuity of resident’s care, and
following organizational processes.
In addition to autonomy and participation in operational decisions, the participants identified good
teamwork as a core element of empowerment. Colleagues are caring for each other was a newly
gained category of nurses ́ perception of organizational culture after the intervention. Caring for
residents and caring for each other were observed to be critical aspects of a nursing home ́s culture.
A flat hierarchy and being allowed to state one’s opinion honestly are important requirements for the
leadership in an empowering organization. Flexibility in problem solving strategies appeared as a
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new category at t1 and seem to be an effect of the peer group supervision intervention. Being able
to state one’s opinion honestly was also a new aspect at t1 and makes the nurses feel empowered.
Inadequate pay and lack of working material was also a new category gained from the content
analysis of the text material at t1. By reading the transcripts of the interviews and group discussions,
the word “lack” was observed in many sequences. The lexical analysis showed that the word “staff
shortage” was used 16 times, “lack of time” 12 times, “lack” and “lacking” two times, and “lack of
space” one time. “Lack” was observed to be a specific characteristic of the nursing home ́s culture
and contrary to nurses’ desire to be paid adequately and appreciated, as important factors of
perceived empowerment.
Figure 5 shows the code theory model “nurses ́ perception of empowerment” with scaled and
textual categories at t1. Only if a text sequence shows concrete indications for a judgmental
statement did the coder match the text passage to the appropriate scaling category. If the text
sequence did not match any of the scaling categories, it was considered “not classifiable.” The textual
subcategories were generated inductively from the text material and showed specific,
phenomenological aspects of nurses ́ perception of their empowerment.
Fig. 5 Nurses ́ perception of empowerment at t1
Caring for others was coded 14 times and one of the most intensively discussed motive in the group
discussions and in the individual interviews. Work place close to living place was a motivation to
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work in the nursing home. This motive was coded 13 times. Getting appreciation and recognition for
one’s work performance was 12 times coded and also a strong incentive for the nurses. It is
motivating for nurses if the leader is open-minded (n= 3). Varying work tasks (n= 1) was also
discussed as an incentive for working in the nursing home. Good teamwork is empowering nurses.
Their understanding of good teamwork was analyzed by the text material. Willingness of working
together and helping each other was coded 25 times and seem to be one of the most meaningful
aspects of a good teamwork. Clear organizational structure and knowing who is responsible for (n=
2) seem to support a good teamwork. Nurses appreciate colleagues’ empathy (n= 2) in the teamwork
and want to be acknowledged with their contribution to the team (n= 1). Participating in
organizational decisions was intensively (n= 12) discussed in the interviews and the group
discussions. More often than participating in administrative and strategic decisions (n= 1)
participating in operative decisions (n= 6) was an issue.
DISCUSSION
What autonomy means for nurses in long-term care facilities and how empowerment is perceived
in the context of an organization ́s culture by nurses was shown by our qualitative material. The
inductively gained sub-categories are specific starting points for subsequent qualitative and
quantitative research and for organization development.
Helping, spiritual feelings, and involvement in patient care have been reported to influence nurses'
job satisfaction (Atefi et al., 2014). There is growing evidence (Wilkes et al., 2015; Crick, 2014) that
being able to help individuals is a central motivation factor of school graduates for choosing nursing
as a profession. We were surprised that spirituality was not a topic found in the interviews and
group discussions of this study, whereas helping each other and encouraging each other were
identified sub-categories as core values of a residential home ́s culture at t1. Helping residents and
ensuring the continuity of residents’ nursing care process despite staff shortages and lack of time
were also observed to be core values of organizational culture from the participants ́ perspective.
Working conditions and organizational culture should support nurses to fulfill their wish to help
each other and to help residents who are in the need of nursing care.
The evidence that organizational culture and climate is influencing nurses ́ outcomes such as job
satisfaction is more robust than the evidence that it influences patient outcomes (MacDavitt et al.,
2007). However, good evidence is reported that nurses ́ job satisfaction and nurses ́ psychological
distress influence patient outcomes (Aiken et al., 2013). Therefore, it is necessary to work on
nurses ́ job satisfaction and nurses ́ empowerment to reduce psychological distress to obtain
improved outcomes for residents. Self-determination in daily life practice is a core element of
residential care. Realizing a resident ́s autonomy requires a nursing workforce to be aware of the
importance of autonomy, having an idea what autonomy means as a concept, respecting a resident ́s
autonomy, and being able to implement self-determined decision making in the nursing care
process.
If nurses experience autonomy themselves in their work environment and in their daily work life,
they can better respect and realize a resident ́s autonomy. Empowering nurses means empowering
residents; thus, as a first step, it is necessary to understand what empowerment means to nurses to
determine starting points for their strengthening. If interventions are used, such as the peer group
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supervision as in our study, risks and side effects must always be considered. The results of the
analysis of the text material in the deductively applied category “importance of participating in
decisions” (fig. 2 and fig. 3) showed diverse levels of importance. Empowerment can result in stress
for nurses if they feel overburdened with a large margin for decision making, especially on an
administrative and strategic level. Adequate and balanced participation in decision making,
especially on the operational level, should be a key element in human resource management.
If the margin for decisions is too narrow, nurses feel stressed and have a dilemma when attempting
to realize residents’ wishes and priorities, as our text material showed. We consider it alarming that
n = 70 text sequences were coded in the category “perceived psychological distress” scaled “high”
at t1 because stress is a critical predictor of decreased work satisfaction and psychological distress
leads to many diseases, sick leave (Kane, 2009; Trybou et al., 2014), nurses ́ early exit of the
profession, and decreased patient outcomes (Aiken et al., 2013). Perceived job control can minimize
these adverse effects of high job demands (Schmidt and Diestel, 2011) and sustain nurses’
workforce. Therefore, a balanced strategy is required to empower nurses and provide them an
adequate margin for decisions concerning everyday job practice at the frontline working with
residents. Peer group supervision can be an effective human resource development instrument to
empower nurses to participate in organizational decisions on an operative level.
Limitations of and reflections on the research process
Although data were collected in a heterogeneous sample, data saturation cannot ultimately be
judged. The investigated theoretical concepts such as nurses ́ perception of organizational culture
and empowerment are highly individual and complex. There could be many more categories and
subcategories that would increase the understanding of these concepts from nurses ́ perspective.
Intercoder reliability was 93%. Finding a consensus regarding how to understand the complex
concepts used in this study and how to use the coding rules was a long-term process that included
intensive discussions among the coders who had varying levels of knowledge and experience in the
field. On the one hand, the process was time-consuming; on the other hand, coders ́ theoretical and
experience-based understandings were reflected intensively. This reflection was crucial for the
coder ́s ability to openly interpret participants ́ perspective when examining the text material.
Furthermore, the coders controlled their understandings by writing memos.
Conducting studies with a qualitative approach in the field of nursing care results in a high workload
for the researcher and the participants. Staff shortages in nursing also influence quality assurance
measures and the opportunity for nurses to participate actively in studies. Transcripts could not be
returned to the participants because of their high workload. The identified categories could not be
validated with the participants of the interviews and group discussions. Working with the text
material and in-vivo codes and using, consequently, the coding rules should minimize the scope of
a too-extensive interpretation of the original text material. The scientific rule-based approach can
be retraced by verifying the matching of the literal quotes to the categories.
CONCLUSION
In this qualitative study many setting-specific categories that were important for nurses ́
empowerment, their motivation, and their perception of a culture supporting their self- determination were observed. The identified categories of nurses ́ perception of organizational
culture deliver a differentiated structure for further research and for a sustainable human resource
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management. To develop a culture of participation and empowerment in nursing homes, concrete
starting points are required. How organization members perceive their own empowerment is
critical information for personnel development. In this study, we learned that the importance of
participation in organizational decisions varies by individual.
Perceived participation and an employee ́s satisfaction with participation in organizational
decisions depends on their expectations and individually weighted importance of participation.
Organizations must find a balance between a member ́s individually adequate autonomy and clearly
defined structures and anticipated decisions. This balance must be adapted individually for every
employee and even for every resident. Residents ́ autonomy cannot be regarded without nurses ́
self-determination and empowerment in the working context. Both concepts interact strongly.
Interventions for strengthening nurses ́ autonomy such as peer group supervision can only be fully
effective if the organizational culture and organizational structures support the peer group
supervision process and the implementation of its solutions to professional problems.
The learning process regarding how to implement and execute a resident ́s individual autonomy in
daily life practice in a nursing home requires empowered nurses who perceive themselves
autonomy in their work environment. Peer group supervision can be an effective strategy to
increase self-determination in nurses ́ working context when nurses get spaces for decision making
with the resident on the operative level and when nurses are supported to implement these
decisions on the administrative level by the management. Theoretische Konzepte, wie die
empfundene Selbstwirksamtkeit und das Empoerment, müssen für das spezifische Feld der
stationären Langzeitpflege aus der Perspektive der Organisationsmitglieder konkretisiert warden,
um Ansatzpunkte für die weiterführende Forschung und die Organisationsentwicklung zu finden.
Die in dieser Studie identifizierten Kategorien liefern wichtige Ansatzpunkte für das Empowerment
der Pflegekräfte.
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