Structural Empowerment and Patient Safety Culture of Nurses Working in Critical Care Units

Clinical Science Research

Structural Empowerment and Patient Safety Culture of Nurses
Working in Critical Care Units
Donna Armellino RN; Division of Infectious Diseases, Department of Medicine, North Shore
University Hospital
Introduction
Medical errors have become a major national concern. The Institute of Medicine (IOM)
reported in 1999 that an estimated one million people are injured by errors in treatment at
hospitals in the United States, with an estimated 120,000 deaths arising from those errors (Kohn,
Corrigan, & Donaldson, 2000). Preventable events that cause errors resulting in pain and
suffering are reported in the media, on television and broadcast radio, and in newspapers and
journals. Unfortunately, these are reports of patients who came to the hospital for care and were
harmed by that care (Donchin et al., 2003; Hayward & Hofer, 2001).
Medical errors are failed processes that are clearly linked to adverse outcomes (Hofer &
Kerr, 2000). Human error may be the result of system failures related to how a process is
designed, the structure of the organization, incompetence due to employee experience and
training, or related to equipment failure. Systems are created and supported by leaders within an
organization. Leaders can redesign workplace processes, structures, training, and equipment
maintenance procedures to eliminate medical error resulting from human error. Errors decrease
and safety increases when human error is considered within system design (Galvan, Bacha,
Mohr, & Barach, 2005).
Safety can be considered when an individual is protected from accidental injury (Kohn at
al., 2000). High-risk industries, such as aviation, are making use of human factor engineering
(HFE). Using a human error approach, safety improvements have been demonstrated in aviation
by improving systems (Wiegmann, Zhang, von Thaden, Sharma, & Mitchell, 2004). With HFE,
it is assumed that people make errors and that systems are devised to control for human error.
In health care, the work environment has been redesigned to decrease medical errors and
increase safety. Creating processes that factor in human error has had a positive influence on
medical errors involving medication administration, anesthetic practices, specimen mislabeling,
drug events, wrong site surgery, hospital-acquired infections, and surgery (Cooper, Newbower,
Long, & McPeek, 2002; Galvan et al., 2005; Micheals et al., 2007; Pronovost et al., 2006;
Quillen & Murphy, 2006). Decreasing errors through redesign of the registered nurses (RNs)
work environment has increased patient safety.
Changing the nurses work environment has been shown to influence patient outcomes.
Needleman, Buerhaus, Mattle, Stewart, and Zelevinsky (2002) used administrative data from 799
hospitals in 11 states to report the relationship between increased hours of nursing care per day
by RNs and rates of adverse outcomes. Aiken, Clarke, Sloane, Sochalski, and Silber (2002)
associated patient-to-nurse ratios and patient mortality rates among 232,342 adult patients
discharged from two hospitals in Pennsylvania. Whittaker, Smolenski, and Carson (2000)
discussed increased medical errors in patients when care is rendered by nurses who are not
certified. Research involving 866 surveys from nurses in 25 critical care units within eight
hospitals in southeastern Michigan suggested that lack of power may contribute to less desired
patient outcomes (Manojlovich & DeCicco, 2007).
It has been reported that empowered nurses report a high quality of nursing care on their
units (Upenieks, 2003), and nurses with increased authority on issues such as safety, cost

Structural Empowerment and Patient Safety Culture of Nurses Working in Critical Care Units
Clinical Science Research
effectiveness, and care exhibit increased empowerment (Parsons, 1998). Health care, like
aviation, is a potentially hazardous industry vulnerable to human error. Healthcare leaders can
learn from systems initiated in aviation by analyzing events leading to medical errors and change
the work environment to control for human error.
Adoption of principles from other industries and integration of these principles into
health care can accelerate progress toward a supportive work environment that facilitates a
patient safety culture. A culture of patient safety is a work environment with employees who
value, believe, practice, and exhibit behaviors and attitudes of safety (Agency for Healthcare
Research and Quality, 2003). According to an integrative review on patient safety culture
performed by Wiegmann et al. (2004), indicators of a patient safety culture include
organizational commitment, management involvement, employee empowerment, reward
systems, and reporting systems.
Organizations that provide health care have a responsibility to deliver safe care. A
healthcare organization must utilize organizational strategies to reduce and eliminate errors
related to human error (Galvan et al., 2005). One potential strategy is to support structural
empowerment within the nurses work environment to create a culture of patient safety
(Armstrong & Laschinger, 2006).
Organizations that demonstrate a culture of safety have employees who perceive
themselves as empowered and function autonomously. Such organizations have a commitment to
promote a proactive approach in decision making on safety initiatives and processes (Laschinger,
1996). Organizations with an institutional infrastructure of employees who are committed to
their organization and hold themselves accountable for the provision of safety promote a culture
of safety (Armstrong & Laschinger, 2006; Wiegmann et al., 2004).
The IOM released a report in 2003 titled Keeping Patients Safe: Transforming the Work
Environment of Nurses. This report highlights the positive association of the nurses work
environment and quality of patient care. Issues in this report include concerns about poorly
designed processes of care, lack of support systems for decision making, and lack of a structured
environment in which nurses work (Page, 2004). All these issues, independently or in
combination, contribute to error. Errors, in any industry, are often the result of a sequence of
events. If the sequence of events is disrupted, the error is unlikely to occur.
Among the solutions proposed for improving the work environment is support for nurse
structural empowerment to develop a patient safety culture that can disrupt these sequences and
thereby reduce errors. Structural empowerment is the ability to access support, information,
resources, and opportunities from ones position in the organization (Laschinger & Havens,
1996). Structural empowerment can be viewed as a necessary feature of a nurses workplace
environment. Quality of the work environment affects feelings of organizational support, access
to resources, organizational commitment, trust, and improved quality of patient care (Laschinger,
2008; Laschinger, Finegan, & Shamian, 2001; Matthews, Laschinger, & Johnstone, 2006;
Patrick & Lachinger, 2005).
Armstrong and Laschinger (2006) linked the quality of nurse practice environments to a
culture of patient safety. Based on the results of their study, they suggested that empowered
nurses practice safely due to workplace conditions that promote provisions for providing safe
patient care. In another study, Upenieks (2003) reported that nurses who feel empowered in their
work environment are more satisfied, committed to the organization, and report high quality
nursing care on their units.

Structural Empowerment and Patient Safety Culture of Nurses Working in Critical Care Units
Clinical Science Research
Healthcare organizations have prioritized safety as a goal. Leaders within organizations
that provide an empowering nurse environment can achieve the organizations goal by providing
a constructive organizational culture (Valadares, 2004). The creation of an empowering nursing
environment influences the nurses perception of a culture of safety (Armstrong & Laschinger,
2006). Logically, one can expect a reduction in medical errors when nurses have a positive
perception of structural empowerment and patient safety culture.
Methods
A descriptive, correlational design was used to report the relationship between structural
empowerment and culture of patient safety. This study was conducted in the adult critical care
units in an 812-bed tertiary hospital in New York. The five critical care units have a total bed
capacity of 85. They include a 16-bed neuroscience care unit (NSCU), an 18-bed surgical
intensive care unit (SICU), a 17-bed medical intensive care unit (MICU), a 12-bed coronary care
unit (CCU), and a 22-bed cardiothoracic care unit (CTU). Patients 18 years of age and older are
cared for on all units.
A convenience sample of 102 RNs with active work status assigned to the cost centers for
the NSCU, SICU, MICU, CCU, and the CTU was surveyed from an estimated population of
nurses available was 257 (200 full-time, 41 part-time, and 16 per diem). The instruments used in
this study were a background data sheet, the Conditions of Workplace Effectiveness (CWEQ-II)
(Laschinger et al., 2001), and the Hospital Survey on Patient Safety Culture (HSOPSC) (Sorra &
Nieva, 2004a). The three anonymous surveys with no identifiable information were distributed
with the RNs paycheck with a cover letter. The RNs were provided four weeks after distribution
to complete the survey. Informed consent was assumed on receipt of the completed survey.
There were no direct benefits to the participant or the units involved in this study, participants
were not compensated for their participation.
The background data questionnaire included 11 questions focused on: gender, birth year,
race, years in nursing, years at hospital, highest degree held, certification in specialty area, type
of certification, job status, the number of hours worked per week, plus a question on salary. The
readability of the tool, based on the Flesch-Kancaid Index, is 7.7. It took no more than 5 minutes
to complete.
The CWEQ-II, instrument contains 19 questions, plus two additional items that measure
global empowerment for the purpose of construct validation. The instrument measures six
components of structural empowerment perceptions of access to opportunity, information,
support, and resources (Laschinger et al., 2001). Two additional scales, the Job Activities Scale
II (JAS-II), and the Organizational Relationships Scale-II (ORS-II) measured formal power and
informal power (Laschinger et al.).
The scoring for the CWEQ-II, JAS-II, and ORS-II incorporates a 5-point Likert-scale,
with scores ranging from none to a lot for each item. The questions are positively worded,
and a higher score indicates a higher level of structural empowerment. Items are summed and
then averaged to obtain a subscale scoring range from 1 to 5. A total structural empowerment
score is calculated by summing scores for all six components. The sum and average of each of
the subscales provide scores ranging from 1 to 5, which are then summed and averaged to create
a total structural empowerment score. Structural empowerment scores range from 6 to 30 with
the higher number representing a higher perception of structural empowerment. Scores ranging
from 6 to 13 are described as low levels of structural empowerment, 14 to 22 as moderate levels
of structural empowerment, and 23 to 30 as high levels of structural empowerment.

Structural Empowerment and Patient Safety Culture of Nurses Working in Critical Care Units
Clinical Science Research
The HSOPSC was designed to measure seven unit-level perspectives of patient safety
culture, three hospital-level aspects of patient safety culture, and three outcome variables, was
used to measure perceptions of patient safety culture. Twelve of the 14 subscales are rated on a
5-point Likert scale. For 31 items, the ratings are 1 (strongly disagree), 2 (disagree), 3 (neither),
4 (agree), and 5 (strongly agree). For 9 items, the ratings are 1 (never), 2 (rarely), 3 (sometimes),
4 (most of the time), and 5 (always). Two subscales request single-item measures. The patient
safety culture scales include: two outcome scales: (a) overall perceptions of safety; (b) frequency
of event reporting; two additional scales are measured via single item measures; and ten patient
safety culture scales: (a) supervisor/manager expectations and actions promoting patient safety;
(b) organizational learning - continuous improvement; (c) teamwork within units; (d)
communication openness; (e) feedback and communication about error; (f) non-punitive
response to error; (g) staffing; (h) hospital management support for patient safety; (i) teamwork
across hospital units; and (j) hospital handoffs and transitions(Sorra & Nieva, 2004b). The
survey takes 10 to 15 minutes to complete. Its Flesch-Kincaid grade level score for readability is
8.2, indicating that an eighth grader should be able to easily read the survey.
Complete CWEQ-II and HSOPSC surveys were those in which 90% or more of the
CWEQ-II and HSOPSC instruments were completed. For questionnaires with less than 10%
missing data, the mean score on that section of the questionnaire was imputed into the missing
question. After all surveys were reviewed, the response rate was calculated. The responses to the
surveys answered three research questions:
1. What are the perceptions of structural empowerment among nurses working in critical care
units?
2. What are the perceptions of patient safety culture among nurses working in critical care units?
3. What is the relationship between perceptions of structural empowerment and patient safety
culture among nurses working in critical care units?
Results
Two hundred fifty-seven RNs received survey packets with their paychecks on August
28, 2008. Data collection was conducted over a 4-week period and yielded 102 surveys. The
overall response rate was 40%. The number of completed surveys exceeded the minimum
number (N = 82) of participants needed for a medium effect size ( =.30), a = 0.05, and power
(1- ) = .80 (Burns & Grove, 2005).
The personal characteristics of the sample included gender, age, race, and years in
nursing. The majority of participants were female (n = 92, 90.2%); 10 were male (9.8%). Ages
ranged from 23 to 58 years, with the mean age 38.59 (SD 8.46) for the 96 RNs who responded
to this question (95%). Most participants were White/Caucasian (n = 50, 50%); 2 identified
themselves as American Indian/Alaskan (2%); 7 Asian (7%); and 9 each Black/AfricanAmerican and Hispanic/Latino (9%). One participant identified as a Pacific Islander (1%), 5
responded other (5%), and 17 (16.83 %) did not answer the question pertaining to race. Years
of experience as a RNs ranged from zero to 36 years (n = 100). The mean number of years
worked was 12.28, SD 8.57.
Participants were asked to provide information on their highest degree held, certification
in a specialty area, and type of certification. The majority (n = 59, 58.42%) had a minimum of a
4-year degree. Twenty-seven (26.73%) of the participants had a diploma or an associate degree
in nursing; 15 (14.85%) had a masters degree. Thirty-one (31%) had certification; and 69 (69%)
did not have certification.

Structural Empowerment and Patient Safety Culture of Nurses Working in Critical Care Units
Clinical Science Research
Work-related characteristics included years worked at the hospital, full-time or part-time
status, and two questions pertaining to salary. The number of years at the hospital ranged from
zero to 27 years with a mean of 9.33 (n = 98, SD = 6.74). Only RNs with a minimum of 8 weeks
of employment participated in the survey process. The median number of years worked at the
hospital was 8. Most particpants (n = 88, 86.27%) worked full-time; 14 (13.76%) worked parttime/per diem. The salary range was from $60,000 to $129,000 (n =102); a majority of
respondents indicated a salary increase in the past year (n = 59, 57.84%).
Research Question 1. What are the perceptions of structural empowerment among
nurses working in critical care units?
The CWEQ-II scores of the 6 subscales are summed to create the total structural
empowerment score (score range 6-30). According to Laschinger and colleagues (2001), scores
less than 14 indicate low levels of structural empowerment; scores ranging from 14 to 22
indicate moderate levels of structural empowerment; and scores of 23 to 30 indicate high levels
of structural empowerment. The 101 respondents perceived themselves to be moderately
empowered. The total structural empowerment score ranged from 12.00 to 28.17. A majority of
the respondents (n = 80, 79.2%) indicated a moderate (14 - <23) level of structural empowerment
(M = 20.55, SD3.0); 2 (1.98%) had a low level of structural empowerment, and 19 (18.81%) a
high level of structural empowerment. The mean score for the sample was 20.55 (SD 3.10).
Scores for each of the six CWEQ-II subscales (opportunity, information, support,
resources, formal power, and informal power) were computed. Scores on the opportunity
subscale ranged from 2 to 5 (M = 4.19, SD 0.78). Scores on the information subscale ranged
from 1.67 to 5 (M = 3.25, SD 0.77), the support subscale ranged from 1.67 to 5 (M = 3.32, SD
0.77), the resources subscale ranged from 1 to 5 (M = 3.09, SD 0.73), formal power,
measured by the JAS, resulted in scores ranging from 1.33 to 4.66 (M = 2.99, SD 0.65), and
informal power, measured by the ORS had scores ranging from 2 to 5 (M = 3.69, SD 0.72).
Research Question Two. What are the perceptions of patient safety culture among nurses
working in critical care units?
For the 12 scales, minus the single-item questions; a score was calculated based on the
average percentage of positive responses to the survey items in that scale, divided by the total
number of positive, neutral, and negative responses for each respective item. Negatively worded
questions were reversed before the percentage positive response was calculated. The measures of
central tendency and the percentage of positive response results for each scale on the HSOPSC
instrument are listed in Table 1.
Table 1. HSOPSC Measures of Central Tendency and Scores (N = 98)

Structural Empowerment and Patient Safety Culture of Nurses Working in Critical Care Units
Clinical Science Research
HSOPSC Dimension
Frequency of Events Reported
Overall Perception of Safety
Supervisor/Manager Expectations
Organizational Learning
Teamwork Within Units
Communication Openness
Feedback and Communication About Error
Non-Punitive Response to Error
Staffing
Hospital Management Support for Patient
Safety
Teamwork Across Units
Hospital Handoffs and Transitions

SD

Range

% Positive

95
98
98
98
98
98
98
98
98
98

0.48
0.50
0.69
0.68
0.74
0.61
0.60
0.21
0.40
0.52

0.43
0.31
0.36
0.33
0.33
0.4
0.38
0.32
0.29
0.39

0.0 -1.0
0.0 -1.0
0.0 -1.0
0.0 -1.0
0.0 -1.0
0.0 -1.0
0.0 -1.0
0.0 -1.0
0.0 -1.0
0.0 -1.0

47.72%
49.74%
68.88%
68.37%
74.40%
60.54%
60.37%
21.09%
39.12%
52.38%

98
98

0.43
0.40

0.36
0.35

0.0 -1.0
0.0 0.94

42.35%
43.37%

Each participant gave the hospital a safety grade. Fifteen (19.74%) indicated a safety
grade of A for patient safety; 50% of the respondents (n = 38) indicated a grade of B; and 23
(30.3%) gave a grade of C or D. No participant gave an E, a failing grade, for safety. A
majority (62.5%) did not report an event that almost caused or caused a medical error within the
past 12 months; 30 (37.5%) reported 1 to 7 events with a majority reporting fewer than 3 events
(31.25%).
Research Question Three. What is the relationship between perceptions of structural
empowerment and patient safety culture among nurses working in critical care units?
The CWEQ-II total structural empowerment score and the percent positive for each scale
on the HSOPSC instrument were analyzed using a Pearson correlation coefficient. Correlation
results are listed in Table 2.
Table 2. Correlation between Total CWEQ-II Score and HSOPSC Scales (N = 98)
HSOPSC Dimension
Total Empowerment Score
Frequency of Events Reported
0.01
Overall Perception of Safety
0.32*
Supervisor/Manager Expectations and Actions
0.26 *
Organizational Learning and Continuous Improvement
0.34**
Teamwork Within Units
0.35*
Communication Openness
0.28**
Feedback and Communication About Error
0.41***
Non-Punitive Response to Error
0.19
Staffing
0.27**
Hospital Management Support for Patient Safety
0.18
Teamwork Across Units
0.24*
Hospital Handoffs and Transitions
0.13
Note: *p < 0.05, **p < .01, *** p < .001

Discussion
This study had a 40% response rate. The low response rate could be related to the length
of the surveys, completion of a hospital survey within the past two months, concern that the

Structural Empowerment and Patient Safety Culture of Nurses Working in Critical Care Units
Clinical Science Research
survey results could be traced to their identity, and past experience with surveys, results are not
shared with the participants.
The demographic characteristics of the 102 RNs who participated in this study were
compared respondents to the 2004 National Sample Survey of Registered Nurses (NSSRN)
conducted by the U.S. Department of Health and Human Services Health Resources and Service
Administration (HRSA). A majority of the participants were White, and most were females
between 23 to 58 years of age (M = 38.59). The average age in the present study was less than
that of the RNs included in the NSSRN (M = 46.8). A majority of the RNs in this study (70.15%)
had an education that exceeded a diploma in nursing or an associates degree; for the NSSRN, the
rate was 47.2%. Participants in this study worked full-time and earned a salary that exceeded the
average annual earnings of RNs indicated in the HRSA report ($57,785).
A majority of RNs in this study population (n = 80, 79.21%) perceived themselves to be
moderately empowered. The mean structural empowerment score in this study was 20.55 (N =
101), which translates to a moderate level of structural empowerment. Nurse structural
empowerment has been studied extensively by Laschinger and colleagues at the University of
Western Ontario utilizing the CWEQ-II instrument. Researchers have reported structural
empowerment scores among RNs in various health care settings ranging from a minimum total
structural empowerment score of 17.35 to maximum score of 20.04 (Laschinger et al., 2001;
Donahue, Piazza, Griffin, Dykes, & Fitzpatrick, 2008).
The total structural empowerment score in the present study was higher than the total
structural empowerment score in the research conducted by Armstrong and Laschinger (2006) in
which structural empowerment was related to characteristics of a magnet hospital. The higher
structural empowerment of the nurses in the present study may be related to current efforts to
attain magnet recognition. The score was higher than that reported by Donahue at al. (2008) and
lower than that reported by Piazza et al. (2006) for a study population of staff nurses, advanced
practice nurses, and nursing administrators. Differences in these total structural empowerment
scores may be related to geographic region, management commitment to provide access to
opportunity, information, support, and resources, or the diversity within the groups surveyed.
The total structural empowerment score among RNs was higher in the present study than
in previous research (Matthews et al., 2006). The elevated scores may be related to the nurse
executives key role of active participation in the organizations management team and focused
efforts toward creating an environment that affects empowerment structures. Nurses who feel
their work environments are empowering are more satisfied, are committed to the organization,
and report high quality nursing care in their units (Laschinger et al., 2004; Laschinger et al.,
2000; Laschinger, Finegan, Shamian, & Wilk, 2003; Laschinger & Havens, 1997). Increasing
perceptions of structural empowerment by providing a structurally empowering environment can
affect RNs decisions about their patients plan of care and the degree to which they have an
active and central role in organizational decision making. The environment in which RNs work
affects their perceived structural empowerment. The degree to which these variables are related
to perceptions of structural empowerment may warrant additional research.
Perceptions of the culture of patient safety have been assessed in long-term care and
acute care settings (Castle, 2006; Castle at al., 2007; Hellings et al., 2007; Scherer & Fitzpatrick,
2008; Sorra & Nieva, 2004a). The HSOPSC survey has been used with various healthcare
workers, including ancillary staff, management staff, physicians, and administrators. Each
groups perceptions of patient safety culture may differ. In a study performed by Hannah and
colleagues (2004), a project funded under a cooperative agreement with the AHRQ,

Structural Empowerment and Patient Safety Culture of Nurses Working in Critical Care Units
Clinical Science Research
administrators had a tendency to indicate higher scores on the patient safety scales than staff.
Studies conducted exclusively among RNs in the critical care units using the HSOPSC have not
been reported in the literature. The present study provides the most comprehensive information
available on RNs nurses working in critical care.
The higher responses in this research study and the study conduct by Sorra and Nieves
(2004a) were similar for teamwork, communication openness, supervisor/manager expectations,
organizational learning, and continuous improvement. The response rate in this research study
may be related to the development of a rapid response team. This team consists of RNs from the
acute care setting and other clinicians from other disciplines who respond to a patient based on
the patients care needs prior to the situation becoming critical. The RNs work as a team and
provide feedback and communication within the team as well as to the administration and
nursing leadership, develop recommendations to improve the process, and measure the success
of this program to reduce emergency resuscitation calls. The enhanced communications among
the empowered RNs affect the patients hospital care and decreases medical errors (Manojlovich
& DeCicco, 2007).
Patient safety is a major concern for patients as well as those who work in health care and
those responsible for ensuring safe patient care. Assessment of the current perception of patient
safety culture is not as high as one would want when patients lives are at stake (Singer et al.,
2003). With improved measurement tools available, healthcare organizations are beginning to
assess and describe their organizations culture related to patient safety (Singer et al., 2003; Sorra
& Nieva 2004a). An assessment of patient safety culture can be a useful measure for improving
patient safety, describing the patient safety culture of an organization, raising safety awareness,
and identifying opportunities for improvement (Nieva & Sorra, 2003). Despite the lack of proven
best practices, hospitals can learn from the use of a culture of patient safety survey and decide
which scale or scales provide the best opportunity for improvement.
Significant correlations were found between the total structural empowerment score and
questions on the HSOPSC. These findings add to the current work done by Laschinger and
others who have studied structural empowerment. Structural empowerment has a link to culture
of patient safety, as the perception of structural empowerment increased so their culture of
patient safety. This study adds to the limited literature that provides a link between structural
empowerment and culture of patient safety (Armstrong & Laschinger, 2006). It provides support
for improvement of the nurses work environment toward one that is structurally empowering to
foster patient safety and fulfill the request made by Page in the 2004 IOMs report Keeping
Patients Safe. The need for more research on the nurses work environment as it impact patient
safety.
Limitations
The sample of RNs who participated in the study worked within a single, large
tertiary hospital in New York, therefore limiting generalizability to all healthcare settings,
more specifically across geographic borders. There also is concern about the survey
results. Although the study was anonymous, participant concern about subject
identification and confidentiality should be considered a limitation and may not be
reflective of all RNs working within adult critical care units.
Implications for Nursing Practice
Structural empowerment and the culture of patient safety are essential elements to deliver
efficient, competent, and quality care. Identifying the role of the environment in promoting
patient safety can be the starting point for addressing elements that can be altered to change the

Structural Empowerment and Patient Safety Culture of Nurses Working in Critical Care Units
Clinical Science Research
culture of patient safety. The results should raise awareness of administrators, nurse executives,
and staff about key factors in the nurses environment that promotes a safe patient care
environment. Promoting structural empowerment structures within the workplace can influence
the culture of patient safety.
Recommendations for Future Research
Additional studies assessing structural empowerment and a culture of patient
safety and background variables such as age, education, years as a nurse, years at the
hospital, and certification are warranted. This study was conducted among a convenient
sample of RNs. This study should be replicated in another geographic area with a similar
sample or a larger sample including a broader range of healthcare professionals,
including managers.
Summary and Conclusion
This study adds to the extensive literature on structural empowerment within a distinct
group of RNs. The results of this study indicate that RNs within a critical care setting perceive
themselves to be working within a structurally empowering work setting. It also adds to the
literature on the culture of patient safety within an acute care facility. This study adds to the
limited research on the relationship between structural empowerment and the culture of patient
safety among RNs. In conclusion, this study may guide nurse leaders to support a structurally
empowering work setting to achieve a culture of patient safety and reap the benefits of an
empowering workforce and safe, quality patient care.

Structural Empowerment and Patient Safety Culture of Nurses Working in Critical Care Units
Clinical Science Research
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