Empowerment and leadership in intensive care nursing: a multiple case studyAbstract
Objective To analyze the relationships between a leader’s empowering behavior and structural and psychological empowerment in Intensive Care Unit settings.
Methods This qualitative case study was conducted with nursing professionals from intensive care units in three hospitals in southern Brazil. Data collection involved interviews and documentary research. Data analysis followed the content analysis framework proposed by Graneheim and Lundman.
Results Seventy-nine interviews were conducted and 240 documents were accessed. Three topics emerged from the analysis: 1) Organizational influence on empowerment; 2) Leader influence on empowerment; and 3) Nursing professionals’ perception of psychological empowerment.
Conclusion A leader’s empowering behavior and organization influence employee empowerment, with management practices that promote access to information, resources, support, and opportunities. From interviewees’ perspective, this enhances structural and psychological empowerment and, consequently, positively impacts affective organizational commitment and quality of nursing care.
Keywords:
Nurse’s role; Leadership; Empowerment; Quality of health care; Intensive care units
Resumo
Objetivo Analisar as relações do comportamento empoderador do líder com o empoderamento estrutural e psicológico no cenário da Unidade de Terapia Intensiva.
Métodos Estudo de caso com abordagem qualitativa, realizado com profissionais de enfermagem de Unidades de Terapia Intensiva de três hospitais da região Sul do Brasil, por meio de entrevistas e pesquisa documental para a coleta de dados. A análise de dados seguiu o referencial da análise de conteúdo proposto por Graneheim e Lundman.
Resultados Foram realizadas 79 entrevistas e acessados 240 documentos. Três temas emergiram da análise: 1) A influência organizacional sobre o empoderamento; 2) A influência do líder sobre o empoderamento; e 3) A percepção do empoderamento psicológico pelos profissionais de enfermagem.
Conclusão O comportamento empoderador do líder e a organização influenciam o empoderamento dos liderados, com práticas gerenciais que promovem acesso a informações, recursos, apoio e oportunidades. Na perspectiva dos entrevistados, isso potencializa o empoderamento estrutural e psicológico, e, consequentemente, reflete positivamente no comprometimento organizacional afetivo e na qualidade do cuidado de enfermagem.
Descritores:
Papel do profissional de enfermagem; Liderança; Empoderamento; Qualidade da assistência à saúde; Unidades de terapia intensiva
Resumen
Objetivo Analizar las relaciones entre el comportamiento empoderador de los líderes y el empoderamiento estructural y psicológico en el contexto de Unidades de Cuidados Intensivos.
Métodos Estudio de caso con enfoque cualitativo, realizado con profesionales de enfermería de Unidades de Cuidados Intensivos de tres hospitales de la región Sur de Brasil, mediante entrevistas e investigación documental para la recopilación de datos. El análisis de datos siguió el marco referencial del análisis de contenido propuesto por Graneheim y Lundman.
Resultados Se realizaron 79 entrevistas y se accedió a 240 documentos. Surgieron tres temas del análisis: 1) la influencia organizacional sobre el empoderamiento, 2) la influencia del líder sobre el empoderamiento, y 3) la percepción del empoderamiento psicológico por parte de los profesionales de enfermería.
Conclusión El comportamiento empoderador de los líderes y la organización influyen en el empoderamiento de las personas lideradas, con prácticas gerenciales que promueven el acceso a información, recursos, soporte y oportunidades. Bajo la perspectiva de los entrevistados, esto potencializa el empoderamiento estructural y psicológico y, como consecuencia, se refleja positivamente en el compromiso organizacional afectivo y en la calidad del cuidado de en enfermería.
Descriptores:
Rol de la enfermeira; Liderazgo; Empoderamiento; Calidad de la atención de salud; Unidades de cuidados intensivos
Introduction
An Intensive Care Unit (ICU) is an environment characterized by high levels of stress, work overload and intense emotional demands resulting from the psychological impact of caring for critically ill patients,(1) and it is in this context that the nursing team plays a fundamental role, providing intensive care and emotional support to both patients and their families.(2)
In this scenario, nurse leaders can employ leadership resources to develop the nursing team’s autonomy and critical thinking, improving the decision-making process and creating an environment conducive to team empowerment.(3)
By following this path, nurse leaders transform their practice environment by influencing their employees through their professional performance and behaviors.(4)However, for nurses to exercise their leadership role, it is essential that they adopt a leadership model that favors their performance.(5)
Thus, structural (SE) and psychological (PE) empowerment meet the development and practice of nurses’ leadership,(6) especially in critical environments such as ICUs.
Kanter’s Theory of Structural Empowerment emphasizes the organizational conditions necessary for empowerment, highlighting four fundamental structures: access to information; support; resources; and development opportunities.(7)
Conger and Kanungo’s Theory of Psychological Empowerment conceptualizes empowerment as a motivational process based on self-efficacy, in which individuals feel empowered when they realize that conditions that promote feelings of helplessness are removed.(8)
This theory was later expanded by Thomas and Velthouse, who address the individual perspective of empowerment through four cognitions: meaning (value attributed to work); competence (self-efficacy); self-determination (autonomy in decision-making); and impact (influence on organizational results).(9)
From this perspective, leader empowering behavior (LEB) stand out, which is a set of leader behaviors that promotes PE, and can be an antecedent of this, since its main characteristic is the support and facilitation of the autonomy of employees.(10)
Furthermore, LEB promotes shared values, improves worker satisfaction and commitment to the quality of work.(11,12)
The mechanisms of how leader behavior impacts results are not well understood,(13) just as the literature on leadership in nursing is scarce, showing that greater understanding is necessary to promote effective follow-up behaviors.(14)
Therefore, understanding how a nurse leader can promote the empowerment of their team is fundamental in the context of ICUs, because, by providing adequate structural conditions and encouraging psychological aspects of empowerment, a leader strengthens professionals’ bond with the organization and quality of care provided to critically ill patients.
Furthermore, the integration of these theories allows us to understand both the structural aspects and the psychological processes involved in professional empowerment.
Thus, the following guiding question was formulated: how does a nurse leader empower their employees in the ICU?
This study aimed to analyze the relationships between LEB and SE and PE in ICU settings.
Methods
This is a multiple case study, as proposed by Yin,(15) qualitative approach, based on Kanter’s Theory of Structural Empowerment(7) and in Conger and Kanungo’s Theory of Psychological Empowerment(8) and Thomas and Vethouse.(9) The study methodology followed the international protocol COnsolidated criteria for REporting Qualitative research.(16)
A case study involves the development of theoretical propositions, which direct the focus to what should be investigated.(15) Two propositions were developed: 1) LEB promotes the PE of its employees through SE; and 2) SE and PE occur in different ways in different organizations.
A multiple case study protocol was developed, which helps plan data collection, detailing the procedures that will be employed, containing four sections: 1) case study overview with the objective, propositions and readings on the topic to be investigated; 2) data collection procedures, including ethical issues, data sources and contacts at research sites; 3) specific questions to be investigated and possible sources of evidence, such as what information should be collected and why; and 4) script for the case report.(15)
The development of this protocol allowed constructing the semi-structured script used during the interviews, developed with questions that aimed to capture the different elements and concepts of the theoretical frameworks investigated, while maintaining a direct connection with the theoretical propositions and objective of the case study.
The study population included 181 nurses and 537 nursing technicians working in the ICU of three hospitals with different legal status and service networks, one public (service only through the Brazilian Health System (In Portuguese, Sistema Único de Saúde - SUS)), one philanthropic (service only through SUS and health insurance) and one private (service only through health insurance), located in southern Brazil, using intentional sampling as a criterion.
H1 is a teaching hospital with 650 beds, 84 of which are ICU beds. It is affiliated with a public university and offers exclusive care through the SUS both for adults and children.
H2 is a private philanthropic institution with 465 beds, 107 of which are ICU beds, providing services through agreements with health insurance operators, both private and SUS, with the largest portion of services (88.29%) being provided by the latter, both for adults and pediatrics.
H3 is a private hospital with 111 beds, 36 of which are ICU beds, providing services through agreements with private health insurance providers and private health insurance providers for adult patients only.
The study was limited to ICU nursing professionals to ensure the research’s operational, in addition to considering that nursing leadership is crucial for coordinating teams and ensuring the quality of care for critically ill patients.
Data collection began after approval by the Research Ethics Committee and was carried out through interviews with nursing professionals, from November to December 2023, and documentary research, from April to May 2024. Before starting data collection, a pilot test was carried out with five professionals, in order to refine the semi-structured script used in the interviews.
Participant identification was preserved through the anonymization process, in which each participant and each institution received a code.
The sampling method used was non-probabilistic convenience sampling. For ethical reasons, participant recruitment was conducted indirectly, with the support of the heads of each ICU, who invited professionals to participate in the study when one of the researchers was present at the institution.
The interviews were audio-recorded using a sound recording device. Before each interview, the researcher introduced herself, explained the research, its objectives, and participants’ rights. Participants were then given and signed the Informed Consent Form.
During each interview, the researcher recorded information in a field diary, synthesizing participants’ statements and seeking a preliminary interpretation. These were read at the end of each interview and validated by participants. These records were then typed into Microsoft Word®, generating a separate document for each interview.
The closing of interviews was determined by data theoretical saturation.
Participants’ statements were transcribed using Transkriptor®, which, after being reviewed, generated a Microsoft Word® document for each interview.
The data were analyzed in light of content analysis framework proposed by Graneheim and Lundman(17) of deductive approach.(18) Following this framework, the records made during the interviews were considered as units of condensed meaning, a description close to the text, revealing the manifest content.
The interpretation of units of condensed meaning, description close to the text, which followed with the recognition of the subject that each participant spoke about, thus generating categories.
This categorization made it possible to interpret the condensed units of analysis, description close to the text, which underwent a condensation process, which allows for shortening, preserving their core meaning and the essence of discourses, leading to units of condensed meaning, as an interpretation of the underlying meaning, which manifests the latent content.(17)
Thus, the units of meaning, as an interpretation of the underlying meaning, have undergone a process of abstraction,(17) in which it was identified whether the unit of meaning—interpretation of the underlying meaning—was related to organizational, leader, or individual issues. Subsequently, they were interpreted according to theoretical frameworks, identifying the elements of Theory of Structural Empowerment and Psychological Empowerment Theory, which generated an analysis matrix in an Excel® spreadsheet.
Documentary research involved access to institutional documents, made available by the nursing heads of each ICU in the search for data that would help in understanding SE and PE in co-participating hospitals, being useful to complement the collection of data obtained through the interviews.
Data extraction from documents was carried out through field diary entries by one of the researchers, using a previously developed instrument based on theoretical frameworks and the research method, which indicated possible data sources and what should be sought.
The analysis in the documentary research stage was carried out by interpreting the data collected in light of empowerment theoretical frameworks, identifying SE structures and PE cognitions present directly or indirectly in the data obtained.
The study met national and international ethical standards involving human beings under approval 6,467,793 (Certificate of Presentation for Ethical Consideration 69322323.2.3001.0096).
Results
A total of 79 interviews were conducted (H1: n=38; H2: n=19; H3: n=22), with 29 nurses (H1: n=20; H2: n=6; H3: n=3) and 50 nursing technicians (H1: n=18; H2: n=13; H3: n=19). Interviews lasted 36 hours, 29 minutes, and 38 seconds, with an average of 27 minutes and 43 seconds in each interview. During documentary research, 240 documents were analyzed (H1: n=179; H2: n=15; H3: n=46). Primary institutional sources were analyzed, including healthcare documents such as bundle records, shift handover instruments, and management documents such as work schedules, meeting and training records, institutional strategic plan, and description of professional category responsibilities. Interview data analysis revealed that positive perceptions predominated over negative ones. Documentary research data analysis enabled us to identify the relationship between these data and empowerment frameworks. This enabled us to understand how access to SE structures occurs, and how it impacts PE. Three topics emerged from this analysis: 1) Organizational influence on empowerment; 2) Leader influence on empowerment; and 3) Nursing professionals’ perception of psychological empowerment.
Organizational influence on empowerment
Interview data analysis revealed significant aspects related to the organizational environment, enabling the identification of how this favors or weakens empowerment in each institution, highlighting similarities and differences found between the three institutions (Chart 1).
Ways in which each institutional environment favors or weakens empowerment in the institutions studied
There was a predominance of forms that favor empowerment in relation to organizational aspects in two of the investigated institutions: H2 and H3. In H1, a prevalence of elements that weaken empowerment was observed, thus establishing a contrast with the other institutions.
Leader influence on empowerment
Leadership aspects and behaviors that foster empowerment were predominant and, therefore, can be related to LEB. The relationship between leaders and followers is considered good by most, with emphasis on different behaviors, attitudes, and skills that either foster or undermine the empowerment of followers in the three institutions (Chart 2).
Behaviors, attitudes and skills of leaders that favor or weaken the empowerment of employees in the institutions studied
These leaders’ behaviors, skills, and attitudes have a variety of impacts: they improve the organizational climate in the workplace, making it more peaceful, harmonious, positive, collaborative, communicative, equitable, and based on mutual trust; they help work flow better; they encourage good performance among employees; they contribute to continuous improvement; they facilitate daily work; they strengthen motivation; they provide a supportive environment; and they encourage employee retention.
In contrast, it was also expressed how they weaken empowerment, through the negative influence on professional performance, generating a demotivating, poor work environment, low team morale, with work overload, and fatigue.
Nursing professionals’ perception of psychological empowerment
Chart 3 presents the perceptions with positive connotations, which were the majority, and negative connotations regarding the PE cognitions.
Discussion
This research contributes to the advancement of scientific knowledge in the field of intensive care nursing leadership, offering relevant insights for the development of organizational strategies and nurse leaders. For the participating institutions, the results provide practical guidelines for strengthening empowerment structures and leadership development, enabling the implementation of organizational improvements. The results indicate that LEB, through empowerment management practices, vicarious experience, and active implementation, provides access to SE structures, which will favor the PE of employees. Similarly, organizations also contribute to empowerment both directly and indirectly.
The development and strengthening of nursing leadership in the ICU contributes significantly to improving care practices, optimizing the work environment, and increasing the safety and quality of care.(19)
The improvement in the work environment and individual results promoted by leaders can favor PE and positively influence cognitions, because improved performance and a positive organizational climate improve perceptions of effectiveness and the ability to deal with difficulties at work,(20) fostering self-confidence, developing better care and thus increasing their sense of competence and meaning.
LEB contributes to a positive relationship with leaders, recognizing them as a source of support, as well as improving work experiences, feeling supported and valued.
Therefore, strategies and interventions should be implemented for critical care nurses in order to increase PE and improve processes that lead to quality nursing care and strengthening patient safety culture,(21) because it “predisposes to professional satisfaction and contributes to improving the care provided to patients”.(22)
The working conditions offered, the inclusion of professionals in decision-making processes, and healthy interpersonal and professional relationships in the institutions studied improve relationships with work and the institution, contributing to a feeling of professional fulfillment and greater satisfaction.
On the other hand, some behaviors and attitudes of leaders that weaken empowerment were identified, being barriers to access to support structures, information and resources, and some of these could be related to the supervision style, which can directly or indirectly influence PE cognitions, as they negatively affect the work environment, individual results and work processes, leading to a feeling of powerlessness.
The organizational environment can also weaken empowerment when it hinders access to SE structures, directly or indirectly impacting professionals’ active performance, i.e., negatively affecting work experiences by making it difficult to perform work adequately.
Poor people management, poorly structured staffing and reward systems, precarious working conditions, and flawed organizational dynamics and processes compromise PE, as they lead to work overload, stress, feelings of devaluation and disrespect, affecting performance.
Organizations must seek strategies to improve situations that hinder empowerment and work processes, in order to contribute to a better work environment and, consequently, better results,(23) enabling professional autonomy, shared decision-making and strengthening interpersonal relationships, which contributes to greater job satisfaction and, consequently, higher quality of care provided.
Furthermore, a lack of recognition and appreciation from the hospital or staff can lead to negative feelings about tasks and a lack of motivation to achieve high levels of success, resulting in feelings of fatigue and reduced work quality.(24)
Organizational conditions, such as insufficient support leading to professional overload, limited time for planning and delivering care, problems related to sizing, and conflicts associated with administrative and management skills, whose leadership impacts decision-making at the bedside, can lead to an unfavorable perception of environmental control, negatively influencing autonomy perception.(25)
Nursing professional empowerment, through access to development opportunities, inclusion in decision-making processes, improved working conditions and leadership support, is a strategy that contributes to improving commitment at work,(26) as it favors autonomy, professional development and the sharing of experiences with new nurses.
Future research should explore the applicability of these findings in different care contexts, considering the particularities of each healthcare environment.
We suggest developing interventional studies that evaluate the impact of leadership development programs and LEB, in order to contribute to the consolidation of more effective management practices and the implementation of strategies that promote more qualified and safe nursing care.
A limitation of this study is that the findings may not be easily replicable in different settings due to socioeconomic, cultural, or systemic factors that influence nurse leaders’ practices.
Conclusion
The research objective was achieved by analyzing the relationships between LEB and SE and PE, highlighting relevant aspects and contributing to the advancement of knowledge for developing nursing leadership in the ICU. The results obtained and the theoretical basis used for analysis allowed the theoretical propositions to be reached, thus establishing a theoretical foundation for future research in the field of nursing management. Through empowerment management practices, vicarious experience, and active implementation, LEB provides access to SE structures, fostering PE. Similarly, organizations also contribute to empowerment, both directly by providing access to support structures, resources, and opportunities, and indirectly by fostering PE through management practices and vicarious experience. The hospitals studied have unique characteristics that influence their organizational dynamics and the empowerment of nursing professionals. Identifying these characteristics helps understand how these specificities can affect care practices. LEB contributes to ICU nurse leaders’ performance, as it directly influences the work environment and team effectiveness, strengthening both the SE and PE of professionals. Thus, the integration of LEB, SE, and PE creates a virtuous cycle that fosters more effective and humanized leadership in the ICU, contributing to better clinical and organizational outcomes.
Data availability
: The authors did not make the data from this article available in repositories prior to submission.
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Edited by
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Associate Editor:
Alexandre Pazetto Balsanelli (https://orcid.org/0000-0003-3757-1061) Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brasil
