Applied Nursing Research 42 (2018) 9–16

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Applied Nursing Research

journal homepage: www.elsevier.com/locate/apnr

Original article

Correlates of structural empowerment, psychological empowerment and T

emotional exhaustion among registered nurses: A meta-analysis
⁎
Xinyue Zhang, Hongfang Ye , Yuan Li
Nanjing Drum Tower Hospital The Affiliated Hospital of Nanjing University Medical School, Nanjing 210093, China

A R T I C LE I N FO A B S T R A C T

Keywords: Objective: To conduct a meta-analysis on the relationship between structural empowerment, psychological
Structural empowerment empowerment and burnout for registered nurses.
Psychological empowerment Methods: Cross-sectional studies that focused on the correlation between burnout, structural empowerment and
Emotional exhaustion psychological empowerment of nurses from 1990 to date were searched in Cochrane Library, Web of Science,
Nursing
BMJ, Elsevier, PubMed and CNKI databases. Two reviewers conducted critical appraisal, and extracted corre-
lation coefficient (r) values. Tests of heterogeneity (Q-statistic) were performed to investigate the effect sizes.
Result: Twenty-four studies met the inclusion criteria. For registered nurses, the results of the meta-analysis
indicated that there were weak relationship between structural empowerment and emotional exhaustion
(r = −0.2450). In addition, there was a low correlation between structural empowerment and emotional ex-
haustion (r = −0.4301). However, a moderate relationship was seen between structural empowerment and
psychological empowerment (r = 0.5717).
Conclusion: These results are considered useful guides for hospital managers and nursing professionals in for-
mulating policies and regulations aimed at decreasing emotional exhaustion among nurses.

1. Introduction environments are structured, nurses feel empowered by getting utter-

The health and wellbeing of nurses are decreased by factors such as
complicated nursing practice, demanding patient contacts, workloads,
time pressure, and workplace conditions, all of which result in internal
frustration and lead to burnout, especially emotional exhaustion
(Demerouti, Bakker, Nachreiner, & Schaufeli, 2000; Spence Laschinger
& Fida, 2014). Burnout can result in chronic emotional exhaustion
which is overburdened and stewed by workloads (Lindblom, Linton,
Fedeli, & Bryngelsson, 2006). In view of the psychological and physical
health problems of nurses which lead to emotional exhaustion, it is
important to identify factors that cause dissatisfaction in the external
and internal environments (Sarmiento, Laschinger, & Iwasiw, 2004). A
number of studies have identified some degree of association between
employee empowerment and emotional exhaustion (Buerhaus, Staiger,
& Auerbach, 2000; Laschinger, Almost, Purdy, & Kim, 2004). Empow-
erment is defined as capacity in terms of giving power to senergize and
enable employees to attain superior achievements. It covers two as-
pects: structural empowerment proposed by Kanter, and psychological
empowerment proposed by Spreitzer (O'Brien, 2011a; Royer, 2011).
Kanter's theory of power and its structure support the fundamental
frameworks of work empowerment (Kanter, 1993). When the work
most rights to implement their duties. Therefore, nurses show en-
thusiasm, confidence, high level of decision-making right and autono-
mous rights (Sarmiento et al., 2004). As Kanter emphasized, providing
employees with access to opportunities, information, support, formal
and informal power system, and necessary resources enables them to
make great achievements. The empowerment of nurses is beneficial for
improving their attitudes and increasing organizational effectiveness
(Kanter, 1998). This assertion has been testified by direct evidence of a
relationship between structural empowerment and burnout (Boamah &
Laschinger, 2015).
Instead of focusing on the structural empowerment, Spreitzer
(Spreitzer, 1995a; Spreitzer, 1995b) turned to nurses' psychological
empowerment in the workplace which is believed to be one of factors
that prevent emotional exhaustion. Psychological empowerment is an
emotional state which makes employees have confidence in achieving
targets successfully. This sort of empowerment has four dimensions:
meaning, competence, self-determination and impact. The four core
components enable employees to show harmony in work, values, beliefs
and behaviors, meeting demands of work, and influencing crucial de-
cisions within the organization (Spreitzer, Kizilos, & Nason, 1997).
The complementary theories of Kanter and Spreiter suggest that the

⁎
Corresponding author.
E-mail address: 13915969627@163.com (H. Ye).

https://doi.org/10.1016/j.apnr.2018.04.006
Received 23 November 2017; Accepted 18 April 2018
0897-1897/ © 2018 Published by Elsevier Inc.
X. Zhang et al. Applied Nursing Research 42 (2018) 9–16

Potenally relevant studies were

idenfied though database

Idenficaon
searching˄n=1301˅:
Cochrane Library (1);Pubmed (272);
Web of Knowledge (596); Addional studies (n=4)
BMJ(163); Embase (257); CNKI (12) Reference list: 3
Expert recommendaon: 1

Studies remaining due to duplicaon (n=758)

Screening

Excluded(n=672)
Subject: 308
Full-text studies eligible Measurement instrument: 185
Design: 143
(n=86) Language: 12
Full text unavailable: 8
Review: 16

Excluded (n=62) Subject: 14

Full-text studies screened for further Instrument: 12
Eligibility

evaluaon according to the inclusion Not focused on the relaonship: 8

criteria(n=24) No suitable correlaon coefficient
reported : 28

Studies included in quantave synthesis

(n=24)
Included

Studies included in quantave synthesis

(meta-analysis)
(n=24)

Fig. 1. Flow chart of article selection process.

association between nurses' emotional exhaustion and empowerment
(structural empowerment and psychological empowerment) is sig-
nificant. Indeed, some studies have confirmed a degree of correlation
between structural empowerment and psychological empowerment in
nurses' work environment (DiNapoli, O'Flaherty, Musil, Clavelle, &
Fitzpatrick, 2016; Li, Chen, & Kuo, 2008; Tourangeau, Cranley,
Laschinger, & Pachis, 2010).
Previous studies have investigated the independent relationship
between emotional exhaustion and empowerment. However, the degree
of associations have different outcomes with regard to variables such as
age, region and economic factors. Some studies reported moderate
correlation between structural empowerment and emotional exhaus-
tion, whereas other studies reported little association between these
variables. In some studies, the association was reversed. In view of
these disparities, the present study used meta-analysis of correlates
relating emotional exhaustion, structural empowerment and psycholo-
gical empowerment of registered nurses to investigate the overall sta-
tistical correlation. The findings are expected to guide nursing man-
agers and healthcare professionals in decreasing burnout, and
promoting nurses' health.
2. Methods
2.1. Search strategy
Cochrane Library, Pubmed, Web of science, BMJ, Embase and China
National Knowledge Infrastructure (CNKI) databases were searched
independently by two people. The combinations of keywords and terms
used in the search were “emotional exhaustion/fatigue” and “structural
empowerment; work empowerment/job empowerment/Kanter' theory/
social conformity”, as well as “psychological empowerment/emotional
empowerment/Spreizter theory/social conformity” and “nurse/nur-
sing” Additional papers were retrieved from reference lists of selected
full-text studies for checking potential eligible articles. The search was
limited to publications written in English or Chinese.
2.2. Eligibility criteria
Studies that met the following criteria were included in the meta-
analysis: (a) investigation of the correlation between emotional ex-
haustion, structural empowerment and psychological empowerment;
(b) studies on registered nurses working in hospitals; (c) investigations
on emotional exhaustion, psychological empowerment and structural
empowerment measured by internationally accepted questionnaire
scales with high level of validity and reliability; (d) all relevant studies
containing statistical values calculated with Pearson or Spearman cor-
relation coefficients; (e) all relevant full text publications in peer-re-
viewed scientific journals published either in English or Chinese.
2.3. Instruments
Emotional exhaustion was measured by Maslach Burnout Inventory
(MBI) (Maslach & Jackson, 1981) containing three sub-scales: emo-
tional exhaustion (EE), de-personalization (DP) and personal

10
X. Zhang et al. Applied Nursing Research 42 (2018) 9–16

Table 1
Risk of bias summary.
Serial number Study Study participation Study attrition Measurement Study confounding Statistical analysis and reporting

SE PE EE

15 DiNapoli JM 2016 ++ +++ + + + ++

35 Guo JJ 2105 + ++ + + ++ +
36 Wang X 2013 ++ ++ + + + +
37 Boamah SA 2016 + +++ + + + +
38 Laschinge HKS 2013 ++ +++ + + ++ +
39 O'Brien JL 2011 + +++ + + + + +
40 Laschinger HKS 2009 ++ + + + ++ +
41 Laschinger HKS 2010 + ++ + + + +
42 Cho J 2006 ++ +++ + + ++ +
43 Li X 2014 ++ ++ + + ++ +
44 Wang J 2013 +++ ++ + + ++ +
45 Rong GY 2016 +++ ++ + + + +
46 He Y 2015 ++ ++ + + + +
47 Hochwalder J 2007 + + + + ++ +
48 ÇAVUŞ MF 2010 ++ + + + ++ +
49 Wang C 2014 +++ + + + + +
50 Wu XJ 2014 +++ + + + ++ +
51 Meng LN 2016 + ++ + + + +
52 Knol J 2009 ++ ++ + + + +
53 Stewart JG 2010 +++ +++ + + + +
54 Manojlovich M 2002 + ++ + + + +
55 Bao L 2012 +++ ++ + + ++ +
56 Eman Kamel Hossny 2015 +++ + + + + +
57 Meng LN 2013 +++ + + + ++ +

+: low risk; ++: moderate risk; +++: high risk.

EE: emotional exhaustion; SE: structural empowerment; PE: psychological empowerment.

Table 2
Characteristics of included studies.
Serial number Study, year Nation Sample Instruments Pearson correlation coefficient Fisher Z p Value

15 DiNapoli JM 2016 Ohio, America 280/350 CWEQ-II,PES 0.4 0.4236 < 0.01
35 Guo JJ 2015 Jiangsu, China 1002/1080 CWEQ-II,MBI −0.27 −0.2769 < 0.05
36 Wang X 2013 Heilongjiang, China 385/413 CWEQ-II,MBI −0.1465 −0.1475 < 0.01
37 Boamah SA 2016 Ontario, Canada 1020/3743 CWEQ-II,MBI −0.18 −0.182 < 0.05
38 Laschinge HKS 2013 Ontario, Canada 342/907 CWEQ-II,MBI −0.18 −0.182 < 0.05
38 Laschinge HKS 2013 Ontario, Canada 273/600 CWEQ-II,MBI −0.32 −0.3316 < 0.05
39 O'Brien JL 2011 America 233/500 CWEQ-II,MBI −0.0445 −0.0445 < 0.05
39 O'Brien JL 2011 America 233/500 PES,MBI −0.0349 −0.0349 < 0.01
39 O'Brien JL 2011 America 233/500 CWEQ-II,PES 0.592 0.6807 < 0.05
40 Laschinger HKS 2009 Ontario, Canada 612/612 CWEQ-II,MBI −0.235 −0.2395 < 0.05
41 Laschinger HKS 2010 Ontario, Canada 415/546 CWEQ-II,MBI −0.4 −0.4236 < 0.01
42 Cho J 2006 Ontario, Canada 226/496 CWEQ-II,MBI −0.27 −0.2769 < 0.01
43 Li X 2014 Beijing, China 182/190 PES,MBI −0.71 −0.8872 < 0.01
44 Wang J 2013 Liaoning, China 317/350 PES,MBI −0.463 −0.5011 < 0.01
45 Rong GY 2016 Heilongjiang, China 668/700 PES,MBI −0.211 −0.2142 < 0.01
46 He Y 2015 Hunan, China 639/715 PES,MBI −0.466 −0.5049 < 0.01
47 Hochwalder J 2007 Stockholm, Sweden 838/838 PES,MBI −0.4 −0.4236 < 0.01
48 ÇAVUŞ MF 2010 East Mediterranean of Turkey 194/200 PES,MBI −0.263 −0.2693 < 0.01
49 Wang C 2014 Beijing, China 73/73 PES,NBS −0.39 −0.4118 < 0.01
50 Wu XJ 2014 Jiangsu, China 103/107 PES,MBI −0.31 −0.3205 < 0.01
51 Meng LN 2016 Tianjin, China 244/350 CWEQ-II,PES 0.603 0.6978 < 0.01
52 Jeannette K 2009 Netherlands 519/847 CWEQ-II,PEI 0.452 0.4872 < 0.01
53 Stewart JG 2010 Connecticut, America 72/460 CWEQ-II,PES 0.24 0.2448 < 0.05
54 Manojlovich M 2002 Ontario, Canada 347/600 CWEQ,PES 0.53 0.5901 < 0.05
55 Bao L 2012 Shanghai, China 206/234 CWEQ-II,PES 0.578 0.6595 < 0.01
56 Eman Kamel Hossny 2015 Assiut, Egypt 136/136 CWEQ-II,PES 0.298 0.3073 < 0.05
57 Meng LN 2013 Tianjin, China 233/240 CWEQ-II,PES 0.56 0.6328 < 0.01

accomplishment (PA). Besides, burnout was also viewed as multi-di-
mensional: emotional exhaustion (EE), cynicism (CYN) and inefficacy
(Maslach, Jackson, & Leiter, 1996). Emotional exhaustion is considered
the core component (Chaudhuri, Yeatts, & Cready, 2013; Leiter, Harvie,
& Frizzell, 1998; Sarmiento et al., 2004; Schaufeli, Bakker, Hoogduin,
Schaap, & Kladler, 2001).
Structural empowerment was measured by Conditions of Work
Effectiveness Questionnaire (CWEQ-II) (Spence Laschinger, Sabiston,
Finegan, & Shamian, 2001) consisting of 19 items and 6 sub-scales:
opportunity, information, support, resources, formal power, and in-
formal power. In particular, formal and informal power facilitate access
to the other domains of structural empowerment, which are considered
the primary significant factors (Laschinger, Finegan, Shamian, & Wilk,
2001).
Psychological empowerment was assessed using Psychological
Empowerment Scale (PES) (Spreitzer, 1995a) which included 4 sub-
scales: meaning, competence, self-determination and impact.

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X. Zhang et al. Applied Nursing Research 42 (2018) 9–16

Fig. 2. Summary Fisher Z between structural empowerment and emotional exhaustion.

Fig. 3. Result of sensitivity analysis.

Fig. 4. Summary Fisher Z between psychological empowerment and emotional exhaustion.

2.4. Study selection 2.5. Critical appraisal of quality

In line with PRISMA guidelines for meta-analysis (Moher et al.,
2009), EndNote X7 reference management software was used to find
duplicates after collecting the inclusive papers. Then, titles and ab-
stracts were used to identify applicable studies. Finally, the eligibility
criteria were used to screen and determine the suitability of the pub-
lications.
Twenty-four eligible papers were selected. To score their qualities,
at least two judges carried out independent assessment on them using
the Quality In Prognosis Studies (QUIPS) tool, a modified evaluation
tool based on previously published article (Hayden, van der Windt,
Cartwright, Cote, & Bombardier, 2013). The adjusted version included
5 bias domains: study participation, study attrition, measurement of
empowerment and emotional exhaustion, confounding factor, statis-
tical analysis and reporting. These items were rated low, moderate or
high risk of bias. With regard to the overall risk, studies with low risk of

12
X. Zhang et al. Applied Nursing Research 42 (2018) 9–16

Fig. 5. Result of sensitivity analysis.

Fig. 6. Summary Fisher Z between structural empowerment and psychological empowerment.

Fig. 7. Result of sensitivity analysis.

bias in most important domains were rated high. However, the sum-
mated grade for overall study quality was not approved by researchers
according to the Cochrane Risk of Bias tool (Higgins et al., 2011) and
Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool
(Whiting et al., 2011).
2.6. Data extraction and transformation
Two reviewers separately conducted the data extraction from each
publication using a designed form listing the following variables as
heads: authors, year of publication, country where the study was done,
sample size, quantitative measurements regarding nurses' emotional
exhaustion, structural empowerment and psychological empowerment,
Pearson' or Spearman's correlation coefficients, transformed Fisher Z
and p-values. Prior to the meta-analysis, Formula (1) (see below) was
used to convert Spearman correlation coefficients to Pearson correla-
tion coefficients so as to maintain consistency of correlation coefficient
and conveniently calculate the pooled effect sizes (Chen et al., 2013;
Rupinski & Dunlap, 1996). Next, a Fisher Z transformation was carried
out (Formula (2)) in order to make all the Pearson's correlation coef-
ficients conform to approximately normal distribution and avoid in-
terference of population correlation on variance (Borenstein, Hedges,
Higgins, et al., 2009). Thereafter, meta-analysis was conducted to
generate the Fisher Z. Finally, the summary Fisher Z was transformed

13
X. Zhang et al.
into summary r which represented the correlation coefficient among
three elements (Formula (3)).
6 −1 rp
Formula 1: rs = sin
π 2 (1)
(rs: Spearman correlation coefficients; rp: Pearson correlation coef-
ficient)
1 + rp
Formula 2: Fisher Z = 0.5∗1n
1 − rp (2)
e2∗z − 1
Formula 3: Summary r =
e2∗z + 1 (3)
(z represents for Summary Fisher Z)
2.7. Statistical analysis
Meta-analysis was conducted on eligible papers of two or more in-
dependent correlations using R-3.4.1. The degree of heterogeneity of
the summary effect size among suitable studies was assessed by the chi-
square test and the inconsistency index (I2). If I2 < 50% and p > 0.1,
fixed-effect model was assumed because of the homogeneous effects of
parameters. With I2 ≥ 50% and p ≤ 0.1, random-effect model was se-
lected due to heterogeneous effects (Higgins, Thompson, Deeks, &
Altman, 2003; Huedo-Medina, Sanchez-Meca, Marin-Martinez, &
Botella, 2006). If remarkable heterogeneity was reported, sensitivity
analyses and sub-group analyses were performed to further unravel the
correlations across the studies (Virgili, Conti, Murro, Gensini, & Gusinu,
2009).
3. Results
3.1. Search process
A total of 1301 relevant publications were initially seen with the
keywords. After screening, 82 studies with full texts were found sui-
table. These retrieved articles were subsequently evaluated in line with
the inclusion criteria. Three (3) full-text studies were found based on
the snowball search and 1 study was recommended by an expert.
Ultimately, 24 studies (English language = 17; Chinese language = 7)
were deemed suitable for the purpose of the meta-analysis (Bao, Zhang,
Wu, et al., 2012; Boamah, Read, & Laschinger, 2017; Çavuş & Demir,
2010; Cho, Laschinger, & Wong, 2006; DiNapoli et al., 2016; Eman
Kamel Hossny & Youssef, 2015; Guo et al., 2016; He, Zhou, & Hou,
2015; Hochwalder, 2007; Knol & van Linge, 2009; Laschinger, Grau,
Finegan, & Wilk, 2010; Laschinger, Leiter, Day, & Gilin, 2009;
Laschinger, Wong, & Grau, 2013; Li & Yanlan, 2014; Manojlovich &
Laschinger, 2002; Meng, Jin, & Guo, 2016; Meng, Liu, & Shake, 2013;
O'Brien, 2011b; Rong, 2016; Stewart, McNulty, Griffin, & Fitzpatrick,
2010; Wang, Kunaviktikul, & Wichaikhum, 2013; Wang, Liao, Li, et al.,
2014; Wang, Shuzhen, Xiaoqi, et al., 2013; Wu & Shen, 2014). The
following diagram presents the search process and the reason for ex-
clusion (Fig. 1).
3.2. Critical appraisal of quality
All selected studies were evaluated based on the bias of quality
assessment and the results displayed various levels of risk in partici-
pation, sample attrition and interference factors (Table 1). However, all
the studies reported low risk in measurement scales and statistical
analysis, which enhanced their reliability.
3.3. Characteristics of included studies for meta-analysis
The 24 studies were on 15,287 registered nurses, and a total of 9559
participants completed the questionnaire survey. The regions of study,
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Applied Nursing Research 42 (2018) 9–16
raw Pearson correlation coefficient, transformed Fisher Z and p values
are shown in Table 2. In one study (Wang et al., 2013), the Spearman
coefficient was transformed into Pearson coefficient. The weighted
Fisher Z transformation was calculated using Microsoft Excel 2010.
3.4. Results of meta-analysis
The cumulative sample sizes, pooled Fisher Z and 95% confidence
interval (CI) are shown in the following Figures. Random-effects models
were used to analyze the 24 effect sizes stratified into three parts.
3.4.1. Structural empowerment and emotional exhaustion
Eight articles [i.e. (Boamah et al., 2017; Cho et al., 2006; Guo et al.,
2016; Laschinger et al., 2009; Laschinger et al., 2010; Laschinger et al.,
2013; O'Brien, 2011b; Wang et al., 2013)] (n = 4508 registered nurses)
reported correlation between structural empowerment and emotional
exhaustion. According to the meta-analysis [summary Fisher
Z = −0.24, 95% CI (−0.30, −0.17)], structural empowerment was
negatively associated with emotional exhaustion (Fig. 2). Due to the
heterogeneity (I2 = 81%, p < 0.01) seen in random effects model, a
sensitivity analysis was performed to further examine the reason of
heterogeneity. After gradually eliminating the relative studies, the
summary Fisher Z changed to −0.25 (95% CI: −0.25, −0.18) in fixed
effects model and the heterogeneity was lowered to 46% (p = 0.10) for
stable and homogenous outcomes, with the exception of 3 studies [i.e.
37, 39 and 41] (Fig. 3). Correspondingly, the calculated summary r was
−0.2450. The result indicated the level of structural empowerment had
weak effect on emotional exhaustion.
3.4.2. Psychological empowerment and emotional exhaustion
Nine articles [i.e. 39, 43–50] (n = 3247 registered nurses) in-
vestigated the association between psychological empowerment and
emotional exhaustion. Meta-analysis showed that the overall Fisher Z
was −0.38 with 95% CI (−0.53; −0.23). The random effects model
was chosen owing to the high heterogeneity (I2 = 97%, p < 0.01;
Fig. 4). Therefore, a sensitivity analysis was used to figure out that
eliminating 4 studies [i.e. 39, 43, 45 and 48] the outcome was more
stabilized with overall Fisher Z of −0.46 (95% CI: −0.50, −0.43), and
heterogeneity of 47% (p = 0.11) in fixed effects random (Fig. 5). The
summary r was calculated to be −0.4301, which implied that structural
empowerment had a negatively low influence on emotional exhaustion.
3.4.3. Structural empowerment and psychological empowerment
Nine studies [i.e.15, 39, 51–57] (n = 2270 registered nurses) ex-
amined the relationship between structural empowerment and psy-
chological empowerment. The overall Fisher Z among these studies was
0.55 (95% CI: 0.47, 0.63). Obvious heterogeneity was exhibited
(I2 = 88%, p < 0.01) in random effects model (Fig. 6). From the result
of sensitivity analysis, 4 studies [i.e. 15, 52, 53 and 56] were excluded
to get the final overall Fisher Z at 0.65 (95%: 0.62, 0.69). There was no
obvious heterogeneity (I2 = 33%, p = 0.20) in fixed effects model
(Fig. 7). The summary r was transformed to 0.5717 to indicate a
moderate correlation between structural empowerment and psycholo-
gical empowerment.
4. Discussion
4.1. Structural empowerment and emotional exhaustion
It has been reported that Chinese nurses experience more emotional
exhaustion than nurses from Western countries because they undertake
more tasks and experience more work stress (Guo et al., 2016). How-
ever, the emotion of all clinical nurses is affected by the organization
environment in terms of access to information, support, resources and
opportunities related to their duties. Besides, empowerment creates a
flexible work atmosphere for achievement of work targets (Greco,
X. Zhang et al.
Laschinger, & Wong, 2006). Establishing amicable and reliable re-
lationships with superiors, colleagues and subordinates can consolidate
informal power in an organization. Nurses become more structurally
empowered when administrators grant them some autonomy and en-
courage them to participate in decision making (Çavuş & Demir, 2010).
It has been suggested that when nurses work in an empowered nursing
practice environment, the harmonious relationship among their col-
leagues create more opportunities to lower work stress and emotional
burnout. Work environment is the most effective structural factor that
lowers emotional burnout (O'Brien, 2011b).
4.2. Psychological empowerment and emotional exhaustion
The present study also showed that psychological empowerment has
closer negative association with emotional exhaustion than structural
empowerment. Psychological empowerment as a process starts with the
interaction between one's internal characteristics within the organiza-
tion environment (Hochwalder, 2007). Then, the connection between
external environment and inner personal idiosyncrasy is promoted by
empowerment which motivates individual behavior in turn, and helps
in reducing emotional exhaustion of nurses (Çavuş & Demir, 2010;
Spreitzer, 1995a). Other researches have shown the moderating effect
of psychological empowerment was apparent between structural em-
powerment and emotional exhaustion (Meng et al., 2015). Hence, fa-
cilitating personal characteristic in the organization environment not
only makes for a higher degree of empowerment, but also leads to
eliminating a sense of emotional exhaustion.
4.3. Structural empowerment and psychological empowerment
The significant positive relation between structural empowerment
and psychological empowerment indicates that structural factors in the
social environment play an important role in the accomplishment of
tasks by nurses. Numerous studies have indicated that nurses access to
information, support, opportunity, resources, formal and informal
power influence on their psychological state (DeCicco, Laschinger, &
Kerr, 2006; Meng et al., 2016). Psychological empowerment enables
nurses to show more positive attitude, greater confidence, more au-
tonomous rights, and higher feeling of their work impact (Knol & van
Linge, 2009; Stewart et al., 2010). The close correlation emphasizes the
importance of both outer and inner environments (such as workplace
environment, social welfare and improving nurses' consciousness and
autonomous rights).
5. Implications
The results of this study show that the levels of nurses' structural
empowerment and psychological empowerment are negatively corre-
lated with emotional exhaustion, consistent with Kanter's theory and
Spreizter's theory. The results of meta-analysis indicated that nurses'
emotional exhaustion could be relieved though improving the level of
structural empowerment and psychological empowerment.
Administrators play a significant role in creating workplace environ-
ments and atmosphere needed to improve job performance of nurses
(Lucas, Laschinger, & Wong, 2008). In structural empowerment, nurses
are given the “power” to determine appropriate tasks to be done in
situation (Laschinger, Finegan, Shamian, & Wilk, 2004). Therefore,
these positive cognitions of access to opportunities, resources and in-
formation beneficial to their tasks make them take initiative to ac-
complish organization work. Empowered nurses are an important part
of the organization environment.
6. Study limitations
In the first place, this study included a total of 24 articles reporting
on the relationship between structural empowerment, psychological
15
Applied Nursing Research 42 (2018) 9–16
empowerment and emotional exhaustion. However, all of them have
different levels of quality in methodology, using the recommended
evaluation criterion to appraise the risk of bias. Secondly, the three
sensitivity-analysis results confirmed high heterogeneity among the
articles, with the possibility of too many influencing factors, such as
region, economic position of local hospital, social welfare, nurses' ex-
perience, and level of education. Therefore, considering these con-
founding factors without effective measurements being taken, it was
assumed that it was more proper to calculate the summary effect size
with all the inclusive papers, and make the result of be more steady and
reliable using sensitivity analysis to exclude the very different original
research.
7. Conclusion
This study has found that providing nurses with work-related in-
formation, opportunities, resources, support, as well as formal and in-
formal power, can lower their feeling of powerlessness. In addition, the
results suggest that it is vital to keep nurses' values, beliefs, and beha-
viors in congruence with workplace environment. This makes them
have confidence in taking initiatives for achieving job objectives,
thereby impacting positively on the organization's functions. It also
makes nurses to appreciate their professional roles, and improves the
level of their psychological empowerment through optimal use of
workplace condition and environment. From the perspective of external
environment and psychological cognition, nursing managers may give
incentives such as salary, learning resources and training opportunities.
In addition, the relief from psychological burdens is beneficial to relief
from mental exhaustion.
Acknowledgement
This work was funded by Institute for Nanjing University Hospital
Management - Nanjing Drum Tower Hospital The Affiliated Hospital of
Nanjing University Medical School, Nanjing City, China with grant
number of NDYG2017008.
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