An explorative and confirmative factor analysis of the Leadership and Management Inventory-II among staff working in elderly care.

PURPOSE: The Purpose of the study was to investigate the construct validity and internal consistency of the LaMI among staff in the context of elderly care in Sweden. DESIGN/METHODOLOGY/APPROACH: Questionnaire data from a longitudinal study of staff working in elderly care were used. Data were collected using the Leadership and Management Inventory. First data collection was for explorative factor analysis (n = 1,149), and the second collection, one year later, was for confirmatory factor analysis (n = 1,061). FINDINGS: The explorative factor analysis resulted in a two-factor solution that explained 70.2% of the total variance. Different models were tested in the confirmatory factor analysis. The final model, a two-factor solution where three items were omitted, showed acceptable results. ORIGINALITY/VALUE: The instrument measures both leadership and management performance and can be used to continually measure managers' performances as perceived by staff to identify areas for development.

Nurses' assessed self-efficacy levels to medical asepsis and their relation to structural empowerment, work engagement and work-related stress.

BACKGROUND: Nurses' working conditions are important for their well-being at work and for their ability to provide patients with safe care. Self-efficacy can influence employees' behaviour at work. Therefore, it is valuable to study self-efficacy levels to medical asepsis in relation to working conditions. OBJECTIVE: To investigate the relationship between nurses' assessed self-efficacy levels to medical asepsis in care situations and structural empowerment, work engagement and work-related stress. METHODS: A cross-sectional study with a correlational design was conducted. A total of 417 registered nurses and licensed practical nurses at surgical and orthopaedic units responded to a questionnaire containing: the Infection Prevention Appraisal Scale, the Conditions of Work Effectiveness Questionnaire-II, the Utrecht Work Engagement Scale-9 and the Health & Safety Executive Management Standards Indicator Tool. Correlational analyses and group comparisons were performed. RESULTS: The nurses rated high levels of self-efficacy to medical asepsis in care situations. The correlational analyses revealed that correlation coefficients between structural empowerment, work engagement, work-related stress and self-efficacy to medical asepsis were 0.254-0.268. Significant differences in self-efficacy were found in the grouped working conditions. CONCLUSIONS: This study revealed that nurses rated high self-efficacy levels to medical asepsis and, to some extent, this seemed related to structural empowerment, work engagement and work-related stress. This valuable knowledge could enable improvements at the managerial and organisational levels, benefiting both nurses and patients in the long run.

A complex challenge with unclear improvement: the need for involvement, contextualization and facilitation when managers implement a leadership model.

PURPOSE: Management and leadership in health care are described as complex and challenging, and the span of control is known to be a key component in the manager's job demands. The implementation of change can be a challenge in health care, and managers often have roles as implementation leaders. Little attention has been given to how managers perceive the process of implementation. Thus, this study aims to explore second-line managers' perceptions of, prerequisites for and experiences from the implementation of changes in their manager's work conditions. DESIGN/METHODOLOGY/APPROACH: A grounded theory-based qualitative design was used. Data were collected from a purposive sample of nine second-line managers by individual semi-structured interviews. The three stages of initial coding, focus codes and axial coding were used in data analysis. FINDINGS: Three thematic areas were identified: engagement, facilitation and achievement. The second-line managers' descriptions suggest that the change work entails a complex challenge with an unclear result. Involvement, consideration for the context and facilitation are needed to be able to conduct a cohesive implementation process. ORIGINALITY/VALUE: This study findings outline that to succeed when implementing change in complex organizations, it is crucial that managers at different levels are involved in the entire process, and that there are prerequisites established for the facilitation and achievement of goals during the planning, implementation and follow-up.

Healthcare personnel's working conditions in relation to risk behaviours for organism transmission: A mixed-methods study.

AIMS AND OBJECTIVES: To investigate healthcare personnel's working conditions in relation to risk behaviours for organism transmission. BACKGROUND: Healthcare personnel's behaviour is often influenced by working conditions that in turn can impact the development of healthcare-associated infections. Observational studies are scarce, and further understanding of working conditions in relation to behaviour is essential for the benefit of the healthcare personnel and the safety of the patients. DESIGN: A mixed-methods convergent design. METHODS: Data were collected during 104 h of observation at eight hospital units. All 79 observed healthcare personnel were interviewed. Structured interviews covering aspects of working conditions were performed with the respective first-line manager. The qualitative and quantitative data were collected concurrently and given equal priority. Data were analysed separately and then merged. The study follows the GRAMMS guidelines for reporting mixed-methods research. RESULTS: Regardless of measurable and perceived working conditions, risk behaviours frequently occurred especially missed hand disinfection. Healthcare personnel described staffing levels, patient-level workload, physical factors and interruptions as important conditions that influence infection prevention behaviours. The statistical analyses confirmed that interruptions increase the frequency of risk behaviours. Significantly higher frequencies of risk behaviours also occurred in activities where healthcare personnel worked together, which in the interviews was described as a consequence of caring for high-need patients. CONCLUSIONS: These mixed-methods findings illustrate that healthcare personnel's perceptions do not always correspond to the observed results since risk behaviours frequently occurred regardless of the observed and perceived working conditions. Facilitating the possibility for healthcare personnel to work undisturbed when needed is essential for their benefit and for patient safety. RELEVANCE FOR CLINICAL PRACTICE: The results can be used to enlighten healthcare personnel and managers and when designing future infection prevention work.

Staff structural empowerment-Observations of first-line managers and interviews with managers and staff.

AIM: The aim was to study how first-line managers act to make structural empowerment accessible for nursing staff and furthermore to relate these observations to the manager's and their nursing staff's descriptions regarding the staff's access to empowering structures. BACKGROUND: Staff access to empowering structures has been linked to positive workplace outcomes. Managers play an important role in providing the conditions for structural empowerment. METHOD: Five first-line managers were observed for two workdays. Managers and staff (n = 13) were thereafter interviewed. Field notes and interviews were analysed using directed content analysis. RESULTS: The managers displayed intentional actions that could enable their staff access to empowering structures. Managers and staff described the importance of staff's access to empowering structures. CONCLUSION: Staff who perceive to have access to structural empowerment have managers who are present and available. Unanimity among managers and staff existed in regard to the importance of staff having access to structural empowerment. The managers work continually and intentionally, doing many things at the same time, to provide the staff access to empowering structures. IMPLICATIONS FOR NURSING MANAGEMENT: The study shows the importance of promoting managers' awareness of staff's access to structural empowerment and maximizing managers' presence and availability to their staff.

Staff Working Life and Older Persons' Satisfaction With Care: A Multilevel, Correlational Design.

BACKGROUND: The importance of staff working life for staff well-being has been demonstrated in several studies; less research has focused on staff working life and older persons' satisfaction with care. PURPOSE: The study aim was to study relationships between 1) staff assessments of their structural conditions/empowerment in elderly care, psychological empowerment, and job satisfaction and (2) older persons' satisfaction with care. METHODS: A multilevel, cross-sectional, and correlational design was applied using questionnaire data on working life (1021 staff members) and unit-level data (40 elderly care units) on older persons' satisfaction with care. RESULTS: Statistically significant relationships were found between all 3 working life variables and older persons' satisfaction with care. Furthermore, the results revealed an indirect/mediating effect of job satisfaction between structural empowerment and satisfaction with care, but not for psychological empowerment. CONCLUSIONS: Staff structural empowerment, psychological empowerment, and job satisfaction are linked to older persons' satisfaction with care.

Nursing student's expectations for their future profession and motivating factors - A longitudinal descriptive study from Sweden.

BACKGROUND: The shortage of registered nurses is a global concern. Motives to become registered nurses can be to help others, altruism, personal development and career security. Motives in combination with student expectations regarding the role are not explored. OBJECTIVE: To describe students' motives to become registered nurses and their expectations regarding their future profession. DESIGN: A longitudinal descriptive design with a qualitative approach was used to follow nursing students in the beginning, during and at the end of their education. PARTICIPANTS AND SETTING: A purposive sampling of a group with initially 75 students starting a three-year nursing program at a university in Sweden. METHODS: A study specific questionnaire with open-ended questions was used in the beginning, during and the end of the students' education. At data collection two and three, a copy of the earlier answers was attached. Data were analysed using manifest and latent content analysis. RESULTS: An important profession with career opportunities, interesting duties and team work were described. Students expected diversified duties, possibilities for development and work satisfaction. Increased concerns regarding their upcoming work life was described at the end of the education. CONCLUSION: The students had a positive understanding of the profession and perceived their forthcoming role as interesting. The leading role of coordinating patient care was more comprehensive than expected. Supportive conditions and well planned transition periods could strengthen newly graduated nurses in their professional role and could be an important aspect in the future retention of RNs.

First-line managers dealing with different management approaches.

PURPOSE: The purpose of this paper is to contribute new knowledge about how first line managers (FLMs) in elderly care perceive their situation, with a focus on differences in management approaches at the intersection of the central and local parts of the organization. DESIGN/METHODOLOGY/APPROACH: The present study has a qualitative approach and is part of a larger project on FLMs in elderly care. The results presented here are based on a secondary analysis of 15 of the total of 28 interviews carried out in the project. FINDINGS: The main results are twofold: the majority of FLMs perceived differences in management approaches between local and central management; the differences caused some struggle because FLMs perceived that the management system did not support the differences. The two main aspects that caused the FLMs to struggle were differences in the foci of the management levels and difficulties in influencing the conditions of management. ORIGINALITY/VALUE: The results contribute to the debate on what aspects are important to sustainable management of elderly care. It is common knowledge that FLMs have a complex position, intermediate to the central, upper level management and their subordinates at the local level - levels with different foci and interests. The study contributes new knowledge about what these differences consist of and the dilemmas they cause and offers suggestions as to what can be done to reduce both energy waste and the risk of low job satisfaction.

How do first-line managers in elderly care experience their work situation from a structural and psychological empowerment perspective? An interview study.

BACKGROUND: The work situation for first-line managers in elderly care is complex and challenging. Little is known about these managers' work situation from a structural and psychological empowerment perspective. AIM: To describe first-line managers' experiences of their work situation in elderly care from a structural and psychological empowerment perspective. METHOD: Interviews from 14 female first-line managers were analysed using qualitative content analysis. RESULTS: The theme described the managers' work situation as "It's not easy, but it's worth it." In the four subthemes, the managers described their work in terms of "Enjoying a meaningful job," "A complex and demanding responsibility that allows great authority within set boundaries," "Supported by other persons, organisational preconditions and confidence in their own abilities" and "Lacking organisational preconditions, but developing strategies for dealing with the situations." CONCLUSION: The managers described having various amounts of access to structural empowerment and experienced a feeling of meaning, competence, self-determination and impact, that is, psychological empowerment in their work. IMPLICATIONS FOR NURSING MANAGEMENT: It is vital that first-line managers have access to organisational support. Therefore, upper management and first-line managers need to engage in continuous dialogue to customize the support given to each first-line manager.

District nurses experiences of precepting district nurse students at the postgraduate level.

District nurses are preceptors of district nurse students at the postgraduate level. These district nurse students are already registered nurses who have graduated and are now studying to become district nurses; this training is at the postgraduate level. As preceptors at the postgraduate level, district nurses play an important role in helping these students to achieve the learning outcomes of the clinical practice part of their education. However, there is a lack of studies on precepting at this level. Thus, the aim was to describe district nurses' experiences of precepting district nurse students at the postgraduate level. The study was descriptive in design and used a qualitative approach. Purposive sampling was used and nine district nurses from seven primary health care units in Sweden were interviewed. Data were analysed using qualitative content analysis. An overall theme "Fluctuating between transferring knowledge and striving for reflective learning" and two subthemes emerged. The preceptors' views on precepting and performance varied depending on the situation. The conclusions is that given the current learning outcomes for clinical practice education at the postgraduate level, district nurses need to be more influenced by preception focused on reflective learning.

Nursing students' reflections on caring for end-of-life patients in a youth volunteer association.

The aim of the study was to describe nursing students' reflections on caring for end-of-life patients in a youth volunteer service. A purposive sample of 11 nursing students in one province in China were interviewed and diaries were collected. The data were analysed using qualitative content analysis. The students described the service as "an empowering care that makes a difference - but not without challenges on different levels". The service was said to provide devoted caring adjusted to the person's need, condition and wishes. According to the students, the service had an impact on them; the internal and/or external support was stimulating and rewarding, whereas deficient support was frustrating and made them feel helpless. They emphasized the need for improvements at different levels. In conclusions, the youth volunteer service empowers both patients and students and can be seen as person-centred care. The students' professional knowledge, skills and ability improved, while these aspects were still perceived as deficient. Appropriate curriculum and training for nursing students are necessary and should be tailored to improving students' caring ability and confidence. Expanding the service was emphasized and suggestions for improvements were identified.

Perceptions of Infection Control Practices and the use of Vignettes to Alter Infection Control Behavior: A Feasibility Study.

AIM: To explore the perceptions of infection control practices among healthcare personnel and evaluate the use of authentic vignettes as a means to alter infection control behavior. METHOD: Four authentic vignettes were used as a part of reflective dialogues with healthcare personnel. An evaluation of the dialogues was performed with six healthcare personnel using the focus group technique. Qualitative content analysis was used to analyze the data. RESULTS: The mind-set to help one another and do one's best in every situation was described as a core aspect in preventing the transmission of microorganisms. Having support, taking personal responsibility, being knowledgeable about infection control practices, and having a reasonable workload were seen to play decisive roles in controlling the spread of infection. Discussing authentic comprehensible vignettes with colleagues during the allotted time was considered a valuable method for improving infection control practices. CONCLUSION: Meaningful insights on how best to use vignettes as a means to improve infection control practice were gained. These findings should be considered when designing theory-driven interventions in different contexts, which are aimed at improving infection control practices in health care.

Relationships between structural and psychological empowerment, mediated by person-centred processes and thriving for nursing home staff.

Person-centred care has been shown to have positive outcomes for patients and for staff. However, the complexity of the link between structural conditions, work in a person-centred manner and outcomes for staff is insufficiently described. We tested the relationship between structural empowerment and psychological empowerment, as mediated by nursing home staff members' self-ratings of working in a person-centred manner, the person-centred climate and thriving. Questionnaires were distributed to staff working in 12 nursing homes in Sweden. A serial mediation model was tested. The results showed that higher access to structural empowerment was related to higher psychological empowerment mediated by staff working in a more person-centred manner, improved person-centred climate, and improved staff ratings of thriving. These results point to the importance of strengthening the preconditions for staff to work in a person-centred manner and nursing home managers play an important role in this.

Empowerment and performance of managers and subordinates in elderly care: A longitudinal and multilevel study.

AIM: To investigate relationships between first-line managers' ratings of structural and psychological empowerment, and the subordinates' ratings of structural empowerment, as well as their ratings of the managers' leadership-management performance. BACKGROUND: Work situations in elderly care are complex. To date, few studies have used a longitudinal, correlational and multilevel design to study the working life of subordinates and managers. METHOD: In five Swedish municipalities, questionnaires were answered twice during 2010-12 by 56 first-line managers and 769 subordinates working in nursing homes or home-help services. RESULTS: First-line managers' empowerment at Time 1 partially predicted subordinate's structural empowerment and ratings of their managers' leadership-management performance at Time 2. Changes over time partially revealed that the more access managers had to structural empowerment, i.e. increase over time, the higher the ratings were for structural empowerment and managerial leadership-management performance among subordinates. CONCLUSIONS: Findings strengthen research and theoretical suggestions linking first-line managers' structural empowerment to their subordinates' structural empowerment and ratings of their manager's leadership-management performance. IMPLICATIONS FOR NURSING MANAGEMENT: Managers with high access to structural empowerment are more likely to provide subordinates access to structural empowerment.

Risk behaviours for organism transmission in health care delivery-A two month unstructured observational study.

BACKGROUND: Errors in infection control practices risk patient safety. The probability for errors can increase when care practices become more multifaceted. It is therefore fundamental to track risk behaviours and potential errors in various care situations. OBJECTIVE: The aim of this study was to describe care situations involving risk behaviours for organism transmission that could lead to subsequent healthcare-associated infections. DESIGN & SETTING: Unstructured nonparticipant observations were performed at three medical wards. PARTICIPANTS & METHODS: Healthcare personnel (n=27) were shadowed, in total 39h, on randomly selected weekdays between 7:30 am and 12 noon. Content analysis was used to inductively categorize activities into tasks and based on the character into groups. Risk behaviours for organism transmission were deductively classified into types of errors. Multiple response crosstabs procedure was used to visualize the number and proportion of errors in tasks. One-Way ANOVA with Bonferroni post Hoc test was used to determine differences among the three groups of activities. RESULTS: The qualitative findings gives an understanding of that risk behaviours for organism transmission goes beyond the five moments of hand hygiene and also includes the handling and placement of materials and equipment. The tasks with the highest percentage of errors were; 'personal hygiene', 'elimination' and 'dressing/wound care'. The most common types of errors in all identified tasks were; 'hand disinfection', 'glove usage', and 'placement of materials'. Significantly more errors (p<0.0001) were observed the more multifaceted (single, combined or interrupted) the activity was. CONCLUSION: The numbers and types of errors as well as the character of activities performed in care situations described in this study confirm the need to improve current infection control practices. It is fundamental that healthcare personnel practice good hand hygiene however effective preventive hygiene is complex in healthcare activities due to the multifaceted care situations, especially when activities are interrupted. A deeper understanding of infection control practices that goes beyond the sense of security by means of hand disinfection and use of gloves is needed as materials and surfaces in the care environment might be contaminated and thus pose a risk for organism transmission.

A longitudinal study of working life among first-line managers in the care of older adults.

AIM: To study whether the number of subordinates plays a role in first-line managers' and subordinates' ratings of empowerment, stress symptoms, and leadership-management performance. The aim was also to study relationships between managers' empowerment and stress symptoms and leadership-management performance. METHODS: A longitudinal and correlational design was used. All first-line managers (n=98) and their subordinates (n=2085) working in the care of older adults in five municipalities were approached. RESULTS: With fewer (≤30) subordinates per manager, there were higher ratings of structural empowerment among managers and subordinates and lower stress symptoms among subordinates, than with ≥31 subordinates. Furthermore, structural empowerment was related to the managers' stress symptoms and leadership-management performance, mediated through psychological empowerment. Moreover, structural empowerment can control/adjust for large numbers of subordinates in relation to stress symptoms. CONCLUSION: The higher FLMs rated their access to empowerment, the lower stress symptoms and higher leadership-management performance they rated over time.

Preceptors' reflections on their educational role before and after a preceptor preparation course: A prospective qualitative study.

During clinical practice, preceptors play an important educational role in helping nursing students become secure and effective practitioners. For this educational role they need adequate preparation. The aim of the present prospective study was to describe preceptors' experiences of their educational role before and after attending a university preceptor preparation course. This 7.5-credit, Master's level course is offered on a part-time basis and covers one semester. The theoretical approach was self-directed and reflective learning. Twentyseven preceptors participated in group interviews before and after the course, and data were analyzed using qualitative content analysis. The findings revealed a shift in preceptors' perceptions. Their view of the educational role changed from being characterized by individual experiences and notions to being guided by personal and formal demands. Before the course, the lack of sufficient preconditions for preceptorship predominated, whereas after the course participants described ways of creating such preconditions. Before the course, the supervisory process was described as teaching, whereas after the course it was described as a learning process for students. Using reflective learning in a preceptor preparation course can develop and strengthen preceptors' view of their educational role and help them manage and create the preconditions for preceptorship.

An intervention targeting fundamental values among caregivers at residential facilities: effects of a cluster-randomized controlled trial on residents' self-reported empowerment, person-centered climate and life satisfaction.

BACKGROUND: In Sweden the national fundamental values for care of older people state that care should ensure that they can live in dignity and with a sense of well-being. Our hypothesis was that a caregiver intervention targeting the national fundamental values would improve perceived empowerment, person-centered climate and life satisfaction among older people living in residential facilities. METHODS: The study was a cluster-randomized controlled trial with a pre- and one post-test design, conducted in 27 units (17 study units) at 12 residential facilities for older people in five municipalities in central Sweden. The units in each municipality were randomly assigned to intervention or control group. The caregiver intervention was carried out using an interpretative approach with eight guided face-to-face seminars, where self-reflection and dialogue were used. Data were collected using questionnaires. The number of residents was 43 (78 %) in the intervention group and 37 (71 %) in the control group. The Chi-square test and Mann-Whitney U-tests were performed to detect differences between groups and Wilcoxon signed rank tests to explore differences in change over time within groups. Furthermore, generalized estimating equation (GEE) models were used to study effects of the intervention controlling for clustering effects. RESULTS: Primary outcome measures were empowerment, person-centered climate and life satisfaction. In the intervention group, improvements at follow-up were found in residents' self-reported empowerment (n = 42; p = 0.001, Median difference 4.0, 95 % CI 1.5;6.0), person-centered climate (n = 42; p ≤0.001, Median difference 8.0, 95 % CI 4.5;11.4) and life satisfaction regarding the factor quality of everyday activities (n = 40; p = 0.033, Median difference 9.7, 95 % CI 1.0;21.9) while disempowerment decreased (n = 43; p = 0.018, Median difference -1.3, 95 % CI -2.0;0.0). In the control group person-centered climate decreased (n = 37; p = 0.002, Median difference -8.5, 95 % CI -13.6;-3.0) and quality of everyday activities (n = 36; p = 0.012, Median difference -11.6, 95 % CI-21.7;-3.4). Change over time between groups was significant for empowerment (p = 0.001, Median difference 6.0, 95 % CI 3.0;9.0), disempowerment (p = 0.006, Median difference -2.0, 95 % CI -4.0;-1.0) and person-centered climate (p ≤ 0.001, Median difference 16.0, 95 % CI 9.7;23.0) and for life satisfaction regarding the factor quality of everyday activities (p = 0.002, Median difference 22.1, 95 % CI 8.2;37.4). Results of GEE confirmed earlier results; revealed interaction effects for empowerment (parameter estimate -5.0, 95 % CI -8.3;-1.8), person-centered climate (parameter estimate -16.7, 95 % CI -22.4;-10.9) and life satisfaction regarding the factor quality of everyday activities (parameter estimate -25.9, 95 % CI -40.3;-11.5). CONCLUSION: When the Swedish national fundamental values were put into practice increases in empowerment, person-centered climate and quality of everyday activities were found among older people with intact cognitive ability living in residential facilities. Limitations to consider are the differences between the two groups at baseline, drop-outs and that neither the data collector nor the outcome assessors were blinded to group assignment of participants. TRIAL REGISTRATION: The study was registered in ISRCTN92658034 in January 2013.

A longitudinal qualitative study of health care personnel's perceptions of simultaneous implementation of three risk assessment scales on falls, malnutrition and pressure ulcers.

AIMS AND OBJECTIVES: In this study, the aim was to understand health care personnel's expectations and experiences of participating in an intervention aimed at the implementation of three assessment scales for fall injuries, malnutrition and pressure ulcers, and the performance of preventive measures in these areas over the period of 18 months. BACKGROUND: Fall injuries, malnutrition and pressure ulcers among older people are challenging issues for caregivers at different levels in the health care system. DESIGN: A descriptive design with a qualitative approach was used to follow health care personnel before, during and after implementation of a care prevention intervention. METHODS: Twelve health care personnel with different professions at the hospital, primary care and municipal care levels participated in a preventive care introduction. Seminars were held at four occasions, with assignments to be completed between seminars. Lectures and group discussions were performed, and three risk assessment scales were introduced. The participants were interviewed before, during and after the introduction. Manifest and latent content analysis were used. RESULTS: The main results are presented in the theme 'Patient needs are visualised through a gradually developed shared understanding' and in five categories. The work approach of performing three risk assessments simultaneously was perceived as positive and central to ensuring quality of care; it was not, however, perceived as unproblematic. CONCLUSION: The participants as well as health care team members showed a positive attitude towards and described the advantages of being given opportunities for shared understanding to improve patient safety and to provide structure for the provision of good care. RELEVANCE TO CLINICAL PRACTICE: The managerial approach of listening to and acting on issues stressed by health care personnel is important to ensure ongoing and future improvement initiatives.

First-line managers' descriptions and reflections regarding their staff's access to empowering structures.

AIM: To elucidate first-line managers' descriptions and reflections regarding their staff's access to empowering structures using Kanter's theory of structural empowerment. BACKGROUND: Good structural conditions within workplaces are essential to employees' wellbeing, and their ability to access empowerment structures is largely dependent on the management. METHOD: Twenty-eight first-line managers in elderly care were interviewed. Deductive qualitative content analysis was used to analyse data. RESULTS: Managers perceived that staff had varying degrees of access to the empowering structures described in Kanter's theory - and that they possessed formal power in their roles as contact persons and representatives. The descriptions mostly started from the managers' own actions, although some started from the needs of staff members. CONCLUSION: All managers described their staff's access to the empowering structures in Kanter's theory as important, yet it seemed as though this was not always reflected on and discussed as a strategic issue. IMPLICATIONS FOR NURSING MANAGEMENT: Managers could make use of performance and appraisal dialogues to keep up to date on staff's access to empowering structures. Recurrent discussions in the management group based on such current information could promote staff's access to power through empowering structures and make job definitions a strategic issue in the organisation.