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Work Settings Utilizing the S.C.O.R.E Model on the Psychological
Empowerment of Hospital Nurses in Cebu City
James Bryll R. Brillante, MANM, RN, Jake C. Napoles, DHCM, MAN, and Resty L. Picardo, DM, JD,
MAN
College of Allied Health Sciences, University of the Visayas , Philippines
ABSTRACT
Amid rising demands in healthcare systems, nurse empowerment has emerged as a critical factor in promoting
resilience, job satisfaction, and quality patient outcomes. This study assesses the relationship between structural
work environment factors—specifically those measured by the S.C.O.R.E. (Safety, Communication, Operational
Reliability, and Engagement) framework—and the psychological empowerment of hospital nurses in Cebu City.
Anchored in Kanter’s Structural Empowerment Theory (1977, 1993) and Spreitzer’s Psychological
Empowerment Theory (1995), the research assessed how workplace conditions and psychosocial variables
influence nurses’ perceptions of meaning, competence, self-determination, and impact in their roles. Utilizing a
correlational predictive design, findings revealed that while respondents perceived the overall work environment
positively, particularly in safety, communication, and operational reliability, their psychological empowerment
levels was high—especially in meaning, self-determination, and impact, with only competence rated moderately.
Notably, teamwork climate, job-related uncertainty, and participation in decision-making were identified as
significant predictors of psychological empowerment. The results suggest that structural support alone does not
guarantee empowerment unless internalized as meaningful by individuals. The study recommends targeted
interventions in nursing practice, education, policy, and research to align organizational structures with personal
empowerment experiences, ultimately enhancing nurse satisfaction, retention, and patient care quality.
Keywords: Psychological empowerment, Structural empowerment, Staff nurses, S.C.O.R.E. model, job
satisfaction, Cebu City.
INTRODUCTION
Nurses in hospitals play a crucial role in influencing patient outcomes, clinical effectiveness, and overall
organizational performance within the high-stress environment of health care. In Cebu City, hospitals face
challenges in meeting the growing demands for quality care and sustainable workforce development, making the
understanding of nurses' psychological empowerment essential. Psychological empowerment is a subjective
process involving motivation and cognition, wherein individuals perceive their ability to engage in meaningful
work, experience autonomy, and feel competent. The framework, which includes meaning, competence, self-
determination, and impact, is increasingly recognized in healthcare literature as a mechanism to enhance
resilience and engagement within the health workforce (Llorente-Alonso et al., 2023).
This study investigates the psychosocial dimensions of empowerment for nurses, focusing on the role of
systemic, cognitive, and organizational resources in enhancing empowerment outcomes. This aligns with the
United Nations Sustainable Development Goal (SDG) 3: Good Health and Well-being, particularly its aim to
guarantee healthy lives and promote well-being for individuals of all ages. Psychologically empowered nursing
personnel contribute to improved patient care as well as increased mental health and job satisfaction among
healthcare workers.
Furthermore, to promote psychological empowerment in healthcare environments, formal interventions
addressing both organizational culture and individual health are necessary. The S.C.O.R.E. (Safety,
Communication, Operational Reliability, and Engagement) instrument is an evidence-based methodology
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designed to evaluate and enhance workplace climate across four domains: Safety, Communication, Operational,
Reliability, and Engagement. Sexton et al., (2019) introduced the S.C.O.R.E. (Safety, Communication,
Operational Reliability, and Engagement) instrument as an enhancement to the widely utilized Safety Attitudes
Questionnaire (SAQ) to address the growing demands of healthcare teams beyond traditional safety metrics.
While the SAQ has been useful in assessing safety culture over the years, its original implementation did not
account for critical contemporary challenges such as burnout, work-life balance, and psychological safety.
Previous studies have consistently demonstrated that psychological empowerment mediates the relationship
between work settings and various employee outcomes, including performance, satisfaction, and retention (Knol
& Linge, 2009). Psychological empowerment is associated with fostering innovative thinking and encouraging
positive workplace behaviors (Sun et al., 2015; Zhang et al., 2018). In the healthcare industry, enhancing job
satisfaction, reducing burnout, and promoting high-quality patient care are considered essential (Lv et al., 2021;
Mathew & Nair, 2021). Recent studies by Zhang et al. (2022) and Saleh et al. (2022) have further examined
empowerment in diverse health care contexts, underscoring its significance in nursing and related professions.
The S.C.O.R.E. (Safety, Communication, Operational Reliability, and Engagement) Survey Instrument,
designed to assess key dimensions of the work environment such as safety, communication, operational
reliability, and engagement, has been utilized in various global studies (Adair et al., 2022; Roth et al., 2021) to
evaluate organizational culture and team dynamics.
Despite the growing body of literature on psychological empowerment and the application of the S.C.O.R.E.
(Safety, Communication, Operational Reliability, and Engagement) model, significant challenges remain,
particularly within the Philippine context. Oducado (2021) examined psychological empowerment in Western
Visayas nurses; this construct remains underexplored in Central Visayas, especially among hospital nurses in
Cebu City. Although the S.C.O.R.E. (Safety, Communication, Operational Reliability, and Engagement)
instrument has been employed to assess work environments, and limited research has explored its relationship
with psychological empowerment, especially within Philippine health care contexts. No prior research has
investigated this relationship in Cebu City. This study aims to address a gap by examining the relationship
between S.C.O.R.E. (Safety, Communication, Operational Reliability, and Engagement) variables and the
psychological empowerment of hospital nurses in the region. The absence of local evidence underscores the need
for additional research, making this study a significant and timely contribution to the literature on nursing
management and psychological health in the Philippines.
This research aims to examine the impact of the S.C.O.R.E. (Safety, Communication, Operational Reliability,
and Engagement) framework components on the psychological empowerment of hospital nurses in Cebu City.
The objective is to determine the correlation between safety, communication, operational reliability, and
engagement characteristics and nurses' self-reported perceptions of their work regarding significance,
competence, self-determination, and impact. The research seeks to offer insights that will assist hospital
administrators and nursing leaders in creating empowering work environments. This study aims to enhance job
satisfaction, increase nurse retention, and improve the quality of patient care. Furthermore, it seeks to address
the deficiencies in existing literature within the region and provide contextual foundations for policy
development and further investigation into nursing management and organizational psychology.
Research Objectives
This study aimed to assess whether the dimensions of work settings (S.C.O.R.E) predicted psychological
empowerment among staff nurses in Cebu City for the second quarter of 2025.
Specifically, it sought to answer the following queries.
1. What was the work settings perceptions of the nurses in terms of:
1.1 safety in terms of:
1.1.1 safety climate;
1.2 communication in terms of:
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1.2.1 teamwork climate; and
1.2.2 local leadership;
1.3 operational reliability in terms of:
1.3.1 improvement readiness;
1.3.2 burnout climate and personal burnout;
1.3.3 work-life balance;
1.4 engagement in terms of:
1.4.1 growth opportunities;
1.4.2 workload
1.4.3 participation in decision-making;
1.4.4 job-related uncertainty;
1.4.5 advancement; and
1.4.6 intentions to leave?
2. What was the psychological empowerment of the nurses in terms of:
2.1 meaning;
2.2 competence;
2.3 self-determination;
2.4 impact; and
2.5 overall psychological empowerment?
3. Which dimension of work setting predicted psychological empowerment among nurses?
4. What psychological empowerment enhancement plan was proposed based on the findings of the study?
Statement of Null Hypothesis
Ho1: The dimensions of work setting of Safety, Communication, Operational Reliability, and Engagement
(S.C.O.R.E.) did not predict psychological empowerment among nurses.
REVIEW OF LITERATURE AND STUDIES
Structural Empowerment. Structural empowerment, or managerial empowerment, focuses on the processes
through which organizational managers allocate their power and authority to employees who have traditionally
lacked decision-making autonomy (Fernandez & Moldogaziev, 2013). Structural empowerment, rooted in
organizational and management theory, focuses on the delegation of power, control, and responsibility from
senior management to frontline workers (Knol & Van Linge, 2009; Maynard et al., 2012). Structural
empowerment fundamentally represents a shift in power that enables employees to actively engage in
organizational objectives, independently address problems, and take ownership of their work. Seibert et al.
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(2011) characterized structural empowerment as a function of organizational practice, encompassing
organizational flattening and policy implementation that promote employee autonomy and initiative.
Key components of structural empowerment include access to essential information, necessary resources,
effective feedback mechanisms, and opportunities for learning and development (Laschinger et al., 2001). The
accessibility of formal job features and organizational policies enabled workers to effectively meet work
requirements and engage in innovative behaviors. Knol and Van Linge (2009), Hebenstreit (2012), and Dan et
al. (2018) identified significant relationships between structural empowerment and workplace innovation. Time
constraints, resource limitations, and restricted access to data have been shown to significantly hinder employee
creativity and motivation (Kesting & Ulhøi, 2010). In organizations that promote equity and foster diversity,
inclusion, and equity (EDI), the delegation of decision-making authority enhances employee confidence in
proposing and implementing significant changes.
Safety, Communication, Operational Reliability, Engagement (S.C.O.R.E). S.C.O.R.E. (Safety,
Communication, Operational Reliability, and Engagement) is an advanced concept derived from the original
Safety Attitudes Questionnaire (SAQ), a tool for assessing safety culture among healthcare providers. Since its
inception more than twenty years ago, the SAQ has achieved worldwide recognition as a reliable assessment
tool utilized in many healthcare environments and translated into other languages (Sexton et al., 2019). The
researchers have gathered, examined, and summarized hundreds of datasets in close collaboration with
healthcare professionals across all tiers, from frontline personnel to senior executives. The extensive use of these
applications has led to significant improvements in methodological rigor and elevated response rates,
establishing the SAQ as a leading tool for safety culture evaluation.
As healthcare systems evolved, the need for a comprehensive and current assessment of organizational culture
also increased. Sexton et al. (2019) identified limitations in existing safety culture tools, noting that burnout,
work-life balance, and psychological safety were not explicitly considered—factors increasingly linked to
clinical outcomes and the sustainability of healthcare improvement initiatives. While constructs such as
teamwork climate and safety climate remain significant, they inadequately capture the complexity of modern
healthcare environments. Measuring psychological safety, defined as the ability of staff to express concerns,
recognize confusion, and engage in continuous learning, has emerged as a critical priority.
The organization has developed the S.C.O.R.E. (Safety, Communication, Operational Reliability, and
Engagement) survey instrument, which integrates themes of reliability, engagement, and operational safety while
addressing the changing goals of burnout prevention and employee wellbeing. The aim is to furnish many
organizational essentials—encompassing human resources, quality initiatives, and leadership strategies—
through a unified tool. The primary objective of S.C.O.R.E. (Safety, Communication, Operational Reliability,
and Engagement) was to simplify the administration and debriefing processes by establishing a singular
actionable goal for each work setting, hence enhancing staff empowerment and patient safety outcomes.
Psychological Empowerment. Given the nature of the job required of nurses as a profession, empowering
nurses in their workplace is simply necessary and crucial to maintaining high-quality healthcare. In turn,
psychological empowerment influences nurses' motivation, job satisfaction, and performance by giving them a
sense of purpose, competence, autonomy, and influence. When it comes to making important decisions,
collaborating with teams, and advocating for patients' needs, empowered nurses are more assured. Additionally,
empowered nurses are more resilient under pressure, which reduces burnout and improves patient outcomes.
According to Rashed and Fekry (2015), empowerment is a concept that has different meanings in different
cultures. Furthermore, empowerment is a complex and comprehensive term with a variety of possible definitions
(Abel & Hand, 2018). The process of determining and eliminating obstacles to empowerment in nursing has
been described as a means of enhancing employees' self-efficacy (Fragkos et al., 2020). According to the various
definitions, empowerment can be defined as a shift toward decentralizing power (Ta'an et al., 2020), the
achievement of goals, the development of one's abilities to bring about positive changes in the workplace, or the
possibility of gaining power (Truss et al., 2017). Van Bogaert et al. (2016) emphasizes the role that employees
play as key stakeholders in decision-making, providing high-quality care, and advancing the objectives of the
organization.
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Skar (2010) defines empowerment as the ability to act, the autonomy to make decisions, and the authority to
make decisions. Empowerment can take shape in structural or psychological forms. Structural empowerment
refers to the conditions within the work environment that facilitate high job performance by providing employees
with information, support, resources, and opportunities for learning and development (Orgambídez-Ramos et
al., 2017). Psychological empowerment refers to an individual's mental state characterized by a sense of control,
competence, and alignment with personal goals (Oladipo, 2009). The framework consists of four primary
dimensions: meaning, competence, self-determination, and impact. Meaning refers to the alignment of an
employee's values, beliefs, and behaviors with workplace requirements. Competence refers to an employee's
belief in their capacity to perform work tasks effectively. Self-determination refers to an employee's perception
of autonomy in selecting and organizing their work tasks. Impact refers to the degree of control an employee
perceives over their work (Manojlovich, 2005; Spreitzer & Doneson, 2005).
Psychological empowerment is crucial for nurses to consistently provide high-quality healthcare. This assertion
is supported by a limited number of prior studies. Al-Shomrani, et. al., (2024) demonstrated that psychologically
empowered nurses exhibit greater autonomy in decision-making, resulting in improved patient outcomes,
enhanced safety, and overall quality of care. In contrast, work environments lacking power, marked by insecurity
and organizational stress, are linked to emotional exhaustion, reduced job satisfaction, and increased burnout
among nursing staff.
Psychological empowerment positively influences nurses' attitudes, confidence, and job engagement. The
environment facilitates flexibility, enabling nurses to develop and perform at their best (Zhang, et. al., 2018).
The absence of empowerment is typically linked to heightened emotional exhaustion and stress, as demonstrated
in studies by Permarupan et al. (2019) and Hochwälder (2007). The findings indicate that access to resources,
knowledge, support systems, and both formal and informal power are essential factors in establishing empowered
work environments.
The concept of empowerment significantly contributes to the enhancement of nurses' mental well-being within
the workplace (Read & Laschinger, 2015). It aids in alleviating job-related stress, a common issue faced by
nurses (Papathanasiou et al., 2014). Previous studies have indicated that 27% of hospital employees reported
experiencing mental health issues such as anxiety, depression, and post-traumatic stress disorder (Tajvar et al.,
2015). Mental health challenges are notably prevalent among nursing professionals, especially within critical
care environments (Sharma et al., 2014). The identical conclusion was likewise reached in the work of Taketomi
et al. (2024). The findings of their research indicate that the psychological empowerment of nurses can be
significantly enhanced by fostering a positive and healthy work environment. The findings contribute to the
development of an attractive and health-conscious work environment that emphasizes the quality and outcomes
of nursing care. This comprehension serves as a valuable foundation for cultivating an environment conducive
to the delivery of exemplary nursing care.
Safety on Psychological Empowerment of Nurses. Safety, or psychological safety, refers to the belief that
individuals can express concerns and ideas without fear of punishment or ridicule (Adair et al., 2022). A
psychologically safe work environment is essential for individuals to learn from failures and participate in a
continuous cycle of reflection and improvement. This concept holds particular importance in the healthcare
sector, where the complexity of patient care is increasing and the stakes are elevated. Psychological safety is
crucial in addressing challenges like high turnover rates, fluctuating team membership, and the necessity for
effective coordination within multidisciplinary teams. In environments that prioritize psychological safety,
questioning, addressing issues, sharing mistakes, proposing solutions, and offering suggestions are common
practices. However, the majority of healthcare workers (HCWs) often refrain from voicing concerns, posing
questions, or seeking clarification due to a lack of psychological safety in their environments (Schwendimann et
al., 2013).
The study by Cinar and Kutlu (2022) investigates the relationship between worker and patient safety culture and
the structural and psychological empowerment of operating room nurses. Therefore, better job satisfaction
among operating room nurses could result from higher rates of structural and psychological empowerment,
which would lead to more secure healthcare service delivery. Additionally, it reiterates the importance of
empowering health professionals and suggests that raising awareness of structural and psychological
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empowerment among employees, managers, and researchers may enhance their use in the workplace, ultimately
resulting in a safer culture for both patients and employees.
Communication on Psychological Empowerment of Nurses. A communication style that facilitates the
exchange of information necessary to resolve conflicts, establish common ground, and transfer authority is
known as "empowering communication" (Bandari, 2020; Arnesen-Trunzo, 2015).Using language that fosters
goodwill rather than phrases that are likely to incite animosity or undermine confidence and self-esteem,
empowered communication helps people with less authority recognize shared needs and values. Improving
relationship quality and taking personal responsibility for one's decisions are the main goals of empowering
communication (Houchens, 2020). Rather than instilling feelings of dread, guilt, blame, or shame, this approach
emphasizes compassion to uplift and motivate (Miller, 2007).
The nursing profession is a prime example of an empowering process that is based on empowering
communication. According to Brown (2002), compassionate communication fosters the empowering process in
nursing organizations. Communication is a vital component of the empowerment process; when change agents
communicate in a courteous, truthful, and straightforward manner, it encourages people to be independent and
self-reliant. However, communication that is unclear, perverted, or devalued can lead to feelings of control and
reliance that undermine empowerment.
This is supported by the findings of the research conducted by Deng and Mao (2011), in which they analyze
whether or not alterations in the levels of communication and psychological empowerment would have an impact
on the feelings of members of the team. Changes in either communication or psychological empowerment, or
both concurrently, were found to result in significant fluctuations in the feelings of team members, as
demonstrated by the findings. Based on the findings of the research, it appears that either enhancing
communication or psychological empowerment can have a positive impact on the emotions of team members,
with the combined effect being even more significant.
Operational Reliability on Psychological Empowerment of Nurses. Operational reliability emphasizes the
consistent and dependable delivery of healthcare services aimed at maintaining patient safety and ensuring high-
quality care. Operational reliability denotes that work processes are standardized and executed consistently in
accordance with design specifications. This suggests the removal of errors and inefficiencies in routine
operations to foster a safer and more efficient care environment (Sexton et al., 2019). This underscores the
necessity of maintaining stable care delivery, particularly in high-stress or high-risk settings, where consistency
significantly influences patient outcomes. Adair et al. (2022) demonstrate a strong association between effective
local-level leadership and enhanced operational reliability. The study additionally identified a correlation
between positive leadership behavior and decreased staff burnout, as well as enhanced safety culture and
operational reliability. A 10-point difference in leadership ratings was associated with a 28% reduction in
burnout risk and a 36% enhancement in teamwork climate (Adair et al., 2022).
Engagement on Psychological Empowerment of Nurses. Employee engagement is characterized as a positive
work attitude, wherein an individual demonstrates physical, mental, and emotional commitment to their work
(Gokenbach & Drenkard, 2011). Engaged employees exhibit significant emotional, rational, and behavioral
commitments to their roles and the organization, often described as an individual's attachment to their workplace.
Kahn's theoretical model of employee engagement identifies three psychological constructs as determinants of
engagement levels: meaningfulness, psychological safety, and availability (Scott et al., 2022). In the healthcare
sector, employee engagement is directly linked to perceptions of fulfillment and purpose in their roles. Kahn's
model posits that employee engagement requires a psychologically safe work environment and adequate
resources.
In order to correlate, Jeve, et. al., (2015). proposes a high and positive correlation between employee engagement
and the quality and safety of patient care since engaged healthcare workers are more likely to provide high-
quality care. Engaged employees exhibit significant emotional, rational, and behavioral connections to their job
and organization, often characterized as an individual's bond with their workplace. By increasing the engagement
of healthcare workers who interact directly with patients and their families, healthcare facilities can better align
their policies and priorities with the objectives of patient-centered care. The work environment significantly
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influences the psychological empowerment of employees. The factors of organizational culture, leadership, job
design, and work environment significantly influence the extent of employee empowerment in the workplace.
An enabling and inclusive work environment fosters autonomy, competence, and purpose, while a restrictive or
micromanaging environment hinders empowerment and motivation.
Work environments that promote participative decision-making and open communication are more likely to
enhance psychological empowerment. Organizations that promote continuous learning and career development
programs enhance employees' sense of competence, thereby reinforcing their perception of their own capabilities
(Deci & Ryan, 2017). Physical work environment impacts psychological empowerment. Workplaces that are
comfortable, organized, and collaborative can boost employee motivation and engagement. Flexible work
models like hybrid or remote employment have been linked to enhanced psychological empowerment due to
increased autonomy and work-life balance (Hassard, et al., 2022).
Well-designed work environments that promote autonomy, competence, and meaning empower employees
psychologically, improving job satisfaction, organizational commitment, and performance. To enhance
employee engagement, companies should consider how their work environment affects psychological
empowerment and make changes to boost intrinsic motivation and well-being.
In addition, research conducted by Taketomi, et al. (2024) provides robust empirical evidence supporting the
relationship between the nursing practice environment and psychological empowerment, indicating that a well-
structured and supportive work setting enhances nurses' psychological empowerment. This aligns with the
broader investigation into the influence of work conditions—specifically safety, communication, operational
reliability, and engagement—on psychological empowerment among staff nurses, as outlined by the S.C.O.R.E
(Safety, Communication, Operational Reliability, and Engagement) instrument. Taketomi, et al. (2024) found
that nurses who perceive their work environment positively experience greater psychological empowerment.
This supports the assumption that organizational factors significantly influence empowerment, which in turn
affects nurse performance, job satisfaction, and retention. The study employed the Practice Environment Scale
of the Nursing Work Index (PES-NWI) to evaluate workplace adequacy and utilized the Psychological
Empowerment Instrument (PEI) to investigate nurses' perceptions of competence, meaning, autonomy, and
impact, which are fundamental dimensions of Spreitzer's Psychological Empowerment Theory. The strong
correlation between these two instruments illustrates that a well-planned and managed nursing work environment
fosters a sense of professional control and motivation in nurses.
This is particularly relevant to the S.C.O.R.E (Safety, Communication, Operational Reliability, and Engagement)
instrument, which examines how various elements of the workplace facilitate empowerment. Ensuring safety in
the work environment and maintaining operational reliability are essential for alleviating stress and enhancing
nurses' confidence in their roles. Furthermore, effective communication and active involvement are critical for
fostering autonomy and influence within the organization. Taketomi et al., (2024) demonstrate that hospitals
actively promoting a healthy work environment enhance psychological empowerment while simultaneously
reducing burnout and turnover, thereby underscoring the importance of fostering an empowering organizational
culture in healthcare settings.
Work Setting. Nursing is a highly skilled and dynamic career that requires ongoing learning and development.
To ensure the delivery of quality and safe care, nurses need to undergo lifelong training in order to advance their
competencies as well as continue to be responsive to the increasing intricacies of the healthcare system. Being
among the most fundamental and ubiquitous health care professions, nursing is an important factor in patient
health and the health institution functionality (Al-Shomrani, et.al., 2024). However, such empowerment has not
yet been fully achieved in practice. The staff nurse work environment in Cebu City has been a subject of much
interest, especially in the situation regarding the issues that impact their performance, job satisfaction, and
retention. One of the most salient issues affecting the nursing practice in the Philippines, particularly in Cebu
City, is the chronic shortage of nurses, which is exacerbated by the fact that the Philippines is a leading exporter
of healthcare professionals. Potot and Amparado (2020) examined government hospitals in Cebu City to assess
the factors influencing nurse retention and resignation. They identified a range of individual, organizational, and
economic variables that impact these decisions among nurses. Organizational factors, such as hospital policies
and job satisfaction, were identified as critical determinants of retention. Furthermore, labor market and
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economic conditions were identified as significant factors in nurse resignation, as nurses often moved to higher-
paying positions overseas or in more profitable healthcare environments.
Cabanas and Dano (2022) contributed additional insights regarding the challenges faced by millennial nurses in
clinical settings. The research indicates that frustrations, challenges, and the emotional burden of nursing practice
are particularly pronounced among younger generations of nurses. Millennial nurses, despite their resilience,
pose unique challenges that require careful consideration from nurse managers. The study suggests that
workplace stress can directly affect the performance and well-being of staff nurses, thereby influencing the
quality of patient care. This emphasizes the necessity for nurse leaders to be attuned to the emotional and
psychological needs of their staff, particularly younger nurses, to foster a supportive and efficient workplace.
Nurse managers face the challenge of redesigning systems and strategies to effectively address the frustrations
and difficulties encountered by millennial nurses.
When it comes to compensation and benefits, which continue to be a significant problem in the healthcare
profession, the work environment is also significantly impacted by these same factors. Estrella et al. (2022)
conducted a study to investigate the degree to which healthcare workers in Metro Manila, Metro Cebu, and
Metro Davao are able to achieve satisfactory job outcomes. An additional finding from the analysis was that one
of the primary challenges faced by healthcare workers is the lack of a competitive wage and benefits package,
and that inadequate financial rewards continue to be a significant driving force behind labor migration. In
addition, the results of online interviews with healthcare workers indicated that worries surrounding salary were
among the most important considerations for nurses when selecting whether or not to remain in their current
positions. According to the findings of the research, it is essential to improve remuneration packages in order to
increase nurse satisfaction and retention in the healthcare system. This is true even though organizational support
and job satisfaction are both extremely important factors.
RESEARCH METHODOLOGY
Design. The research was conducted with the use of a research design known as descriptive, correlational
(predictive) research. Utilizing such a study technique is appropriate for the purpose of investigating the impact
that work settings (S.C.O.R.E) have on the psychological empowerment of nurses who are employed in Cebu
City.
Environment. This study was conducted in Cebu City, Philippines. According to the National Health Facility
Registry of the Department of Health there are a total of nine private hospitals and two public hospitals located
in Cebu City that is within the capital, resulting in a total of eleven hospitals that serves as the setting of the
study.The study focused on hospitals in Cebu City, ensuring the inclusion of nurses from both government-
owned and private medical facilities in the sample. This research encompasses nurses from diverse hospital
environments, providing a comprehensive analysis of how safety in the work settings (S.C.O.R.E) influence
psychological empowerment.
Respondents. Participants of the study were the 334 nurses working in hospitals in Cebu City. To compute the
sample size, since the population is not known, the formula used: n= z2. [p*q]/d2). In this formula, n is the
sample size, P is the estimated proportion of the study variable or construct based on previous studies or pilot
studies (70%), q = 1-P (30%), and d is the margin of error (5%). z is the Z-score or a standard normal deviate
corresponding to (100%, α/2%), where α refers to the significance level or the probability of making a type I
error. The z score for different significance levels is: 1.96 for 5%, 1.28 for 10%, and 2.58 for 1%. With the
hypothetical values being added, the sample size was 323 (Younas, 2019).
Sampling Design. A quota sampling was utilized in this study. According to Fleetwood (2024), a quota sampling
is defined as a non-probability sampling method in which researchers created a convenience sample involving
individuals who represented a population. Researchers chose these individuals according to specific traits or
qualities. They determined and established quotas so that the market research samples would be useful in
collecting data. These samples could then be generalized to the entire population. The final subset was
determined based solely on the interviewer’s or researcher’s knowledge of the population. This process
continued until the quota was achieved.
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Inclusion Criteria. The population of interest consisted of nurses working at hospitals in Cebu City, regardless
of their specialty and had been there for at least one year. This academic study focused on full-time active
hospital nurses because they are the ones who are most immediately exposed to the working conditions that are
being evaluated using the work settings (S.C.O.R.E) instrument.
Exclusion Criteria. The study excluded nurses working in clinics, community health centers, academic
institutions, research institutions, or corporate organizations, as the research focused specifically on hospital-
based staff nurses. Nurses who have worked for fewer than six months or newly employed nurses, such as
probationary nurses, may lack sufficient exposure to workplace behavior to provide meaningful insights on
psychological empowerment.
Instruments. This study utilized a three-part instrument. Both parts were adopted from previous studies. Part
one is the Demographic Profile created by the researcher, part two is the S.C.O.R.E: Assessment of the work
settings (S.C.O.R.E) by Sexton et. al. (2019), part three is the Psychological Empowerment Instrument by
Spreitzer (1995).
Part one is composed of the patient’s name which is optional, their sex either male or female, their age which
are each categorized for every five years starting from 24 up until 60. The questionnaire also included Years of
service from the inclusion criteria of 1 year up until 21 years or more. Finally, it included the different shifts that
are available for nurses in the hospital setting which are eight, ten, and twelve hours and an additional option is
provided to list down if they have a different shift arrangement in their hospital other than what was listed.
Part two is the S.C.O.R.E: Assessment of Your Work Setting (Safety, Communication, Operational Reliability,
and Engagement) developed by Sexton et al. (2019). This tool combined elements from various existing
questionnaires to create a more cohesive and comprehensive assessment. It is designed to evaluate key aspects
of the work environment, including safety, communication, operational reliability, and employee engagement,
with the goal of providing a holistic view of workplace dynamics.
The response scale varied from 1 (strongly disagree) to 5 (strongly agree), indicating that elevated scores signify
more favorable work environment norms for each dimension. Safety climate, comprising seven (7) items, refers
to the degree to which local patient safety norms are characterized by proactivity and positivity, including the
discussion, management, and learning from errors. The teamwork climate, assessed through seven (7) items,
refers to the effectiveness of local interaction norms, including the ability to speak up, resolve conflicts, and seek
clarification of ambiguities. Local leadership encompasses five (5) items related to the extent of communication
by leaders. Improvement readiness, comprising five (5) items and referred to as Learning Environment, denotes
the degree to which quality improvement is facilitated within a workplace through ongoing learning regarding
both strengths and weaknesses in quality. Personal burnout, consisting of five (5) items, referred to as personal
exhaustion, was evaluated using a subset of items from the emotional exhaustion scale. Simultaneously, burnout
climate, referred to as exhaustion climate (five items), addresses similar concepts; however, it evaluates group
dynamics rather than individual emotions. Employing a published methodology, the personal burnout and
burnout climate scores were determined as the 'percent concerning' by calculating the percentage of respondents
within a work environment who achieved a mean equivalent of 'neutral or higher' across all items.
Work-life Balance, measured through eight (8) items, refers to the prevalence of work-life infractions occurring
within the past week, aggregated at the organizational level. The response scale for the work-life climate items
included the following categories: (1) Never (2) Rarely (less than 1 day); (3) Some or a little of the time (1–2
days); (4) Occasionally or a moderate amount of time (3–4 days); (5) All of the time (5–7 days); and (x) Not
Applicable. The Job Demands-Resources Model is the most widely supported of numerous legitimate
approaches for evaluating engagement. This study evaluated workplace demands and resources for healthcare
staff using five JD-R Questionnaire scales: advancement, growth prospects, participation in decision-making,
workload, and job uncertainty. Each of the five factors was assessed on a 5-point Likert scale ranging from 1
(strongly disagree) to 5 (strongly agree). It shows that greater scores on advancement, growth opportunities, and
participation in decision-making imply a positive assessment of these dimensions, but higher scores on
workloads and job uncertainty suggest a negative perception of them. The advancement scale included seven
statements that address promotional chances and financial stability. The growth opportunities scale included six
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items that focus on autonomy and freedom in task execution. The participation in decision-making scale had six
measures that assess clarity and involvement in the decision-making process. The workload scale contained five
components that focus on job pressure and volume. Finally, employment uncertainty was made up of three
components that include job security and retention issues.
Reliability. In the study conducted by Sexton (2019) scale reliability was assessed via Cronbach’s alphas each
component of the instrument with the use of a five-point Likert scale with the exception of Work life balance
which utilized a four-point scale. Under Safety, Safety Climate it has a Cronbach's alpha coefficient of α = 0.87.
Communication is being measured by two components namely: Teamwork Climate with a Cronbach's alpha
coefficient of α = 0.82 and Local leadership with a Cronbach's alpha coefficient of α = 0.94.
As for Operational Reliability this is characterized by four components namely: Improvement Readiness with a
Cronbach's alpha coefficient of α = 0.92, Personal Burnout with a Cronbach's alpha coefficient of α = 0.92,
Burnout Climate with a Cronbach's alpha coefficient of α = 0.90 and Work-life balance with a Cronbach's alpha
coefficient of α = 0.82. Lastly Engagement has five components namely: Advancement with a Cronbach's alpha
coefficient of α = 0.89, Growth Opportunity with a Cronbach's alpha coefficient of α = 0.92, Job Uncertainty
with a Cronbach's alpha coefficient of α = 0.88, Participation with Decision Making with a Cronbach's alpha
coefficient of α = 0.88 and Workload with a Cronbach's alpha coefficient of α = 0.84.
Parametric score and interpretation are as follows: score ranging from 4.20 to 5.00 was interpreted as very high
or strongly positive, indicating a strong favorable perception or experience among respondents. Scores between
3.40 and 4.19 were categorized as high or positive, suggesting generally favorable attitudes or experiences. Mean
scores falling within 2.60 to 3.39 were considered moderate or neutral, indicating an average or balanced
viewpoint without strong agreement or disagreement. Scores ranging from 1.80 to 2.59 were labeled as low or
negative, reflecting an unfavorable perception or experience.
Lastly, scores between 1.00 and 1.79 were interpreted as very low or strongly negative, representing a distinctly
adverse response to the measured construct. As previously mentioned, Work-Life Balance is an exception as it
has an inverse rating system and with an interpretation and parametric score as follows: scores ranging from 1.00
to 1.49 were interpreted as very high or strongly positive, signifying excellent work-life balance with minimal
interference from work-related stressors. Scores between 1.50 and 2.49 were considered high or positive,
indicating generally favorable conditions with only occasional issues. Mean scores within 2.50 to 3.49 were
classified as low or negative, reflecting moderate levels of imbalance and more frequent intrusions of work into
personal time. Finally, scores from 3.50 to 4.00 were interpreted as very low or strongly negative, suggesting
persistent and significant work-life challenges that could adversely affect the well-being of the respondent.
Psychological Empowerment Instrument (Spreitzer, 1995). Part three was the Psychological Empowerment
Instrument (Spreitzer, 1995) to assess the four characteristics of psychological empowerment: meaning,
competence, self-determination, and impact. The scale was thoroughly validated and allowed the researcher to
measure the extent to which nurses view themselves as empowered in their employment. The Psychological
Empowerment Measure consisted of 12 items, evenly distributed across the four dimensions, which were
measured using a Likert scale. The response scale varied from 1 (very strongly disagree) to 7 (very strongly
agree). This tool utilized 7-point Likert scale, being that the scale begins with 1 – Very Strongly Disagree,
followed by 2 – Strongly Disagree, 3 – Disagree, 4 – Neutral, 5 – Agree, 6 – Strongly Agree, and ends with 7 –
Very Strongly Agree. The tool consisted of four subdimensions: meaning (first three items), competence (second
three items), self-determination (third three items), and impact (fourth three items). Each sub dimension can be
analyzed separately by averaging the three items that assess it, or an overall empowerment score can be obtained
by averaging the means of all four subdimensions. The tool's validation was established by Spreitzer (1995;
1996), and it has been effectively applied in over 50 studies across diverse settings, including among nurses,
low-wage service employees, and manufacturing workers.
Reliability. The instrument demonstrated strong validity, with high test-retest reliability and typical validity
estimates for each dimension around 0.80. Additional details on empowerment profiles across various contexts,
as well as normative data for the dimensions, were provided by Spreitzer and Quinn (2001). The parametric
interpretation and scoring were as follows: scores ranging from 6.17 to 7.00 is extremely high empowerment,
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5.31 to 6.16 is very high empowerment, 4.45 to 5.30 is high empowerment, 3.59 to 4.44 is moderate
empowerment, 2.73 to 3.58 is low empowerment, 1.87 to 2.72 is very low empowerment, and 1.00 to 1.86
extremely low empowerment.
Data Gathering Procedures. Transmittal letters were sent to the Dean of the College of Allied Health Sciences.
The study then underwent a design hearing and was submitted to the university’s ethics committee. Once
approved, this signaled the start of respondent recruitment. The actual data collection phase began after all
necessary pre-research procedures were completed, such as obtaining ethical clearance from the university's
ethics review committee and formal permissions from hospital administrators at selected public and private
hospitals in Cebu City. To account for variable hospital protocols and nurse availability, a hybrid approach to
data collection was employed, combining face-to-face and online survey methods. Simultaneously, an online
survey option was made available to nurses who preferred digital access or who worked in facilities with stricter
visitation policies due to infection control or scheduling limitations. The informed consent form and
questionnaire were prepared digitally using a secure platform (e.g., Google Forms or Microsoft Forms), and the
survey link was distributed, with administrative approval, through official hospital email lists, nurse managers,
and private nursing group chats. To ensure data consistency and reliability, the online version was structured and
matched in content to the face-to-face questionnaire. Instructions and contact information were clearly provided
on the first page to assist respondents in case of questions or technical issues. Both formats utilized standardized
and validated data collection procedures to assess psychological empowerment and workplace perceptions. The
latter were analyzed using the S.C.O.R.E. framework, which stood for Safety, Communication, Operational
Reliability, and Engagement. All completed responses, whether collected physically or electronically, were
anonymized and assigned unique codes to protect participants' identities. Physical copies of the questionnaires
were stored in a locked file cabinet, while digital data were saved in encrypted, password-protected cloud storage
accessible only to the main researcher. After data collection, all responses were reviewed for completeness and
consistency before analysis. Data were tallied and collated in Excel format and were submitted for statistical
treatment. The data were presented in tables along with interpretations, implications, and supporting literature
and studies. Finally, after all data were collected, encoded, and verified for accuracy, the researcher disposed of
the paper questionnaires containing participant responses by shredding them and deleted the data obtained
online. This action was undertaken to uphold the confidentiality and privacy of the respondents, in accordance
with research ethics.
Statistical Treatment of Data. Mean Score and Standard Deviation were used to determine the Safety,
Communication, Operational Reliability, and Engagement (S.C.O.R.E.) and the psychological empowerment of
the nurses. Linear Regression was used to analyze whether the work settings predicted psychological
empowerment.
Ethical Considerations. This study adhered strictly to ethical guidelines to ensure the safety, privacy, and
autonomy of all participants, in full compliance with institutional, academic, and professional standards. Prior
to data collection, the research proposal received approval from the University Ethics Review Committee,
confirming the ethical soundness and minimal risk of the study’s methodologies, tools, and procedures.
Presentation, Analysis, And Interpretation Of Data
Table 1 Work Setting Perceptions of the Nurses
Dimensions
Mean score
SD
Interpretation
SAFETY
Safety Climate
3.90
0.577
High or positive
Factor mean
3.90
0.577
High or positive
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COMMUNICATION
Local Leadership
3.84
0.677
High or positive
Teamwork Climate
3.80
0.570
High or positive
Factor mean
3.82
0.546
High or positive
OPERATIONAL RELIABILITY
Improvement Readiness (Learning Environment)
4.03
0.68
High or positive
Burnout Climate and Personal Burnout
3.32
0.90
Moderate
Work-Life Balance
2.66
0.80
Moderate
Factor mean
3.34
0.50
Moderate
ENGAGEMENT
Growth Opportunities
3.18
0.584
Moderate
Workload
3.17
0.555
Moderate
Advancement
3.07
0.598
Moderate
Participation in Decision-making
3.18
0.545
Moderate
Job-related uncertainty
3.13
0.761
Moderate
Intentions to leave
2.67
0.937
Moderate
Factor mean
3.06
0.421
Moderate
Grand mean
3.53
0.370
High or positive
Note. n=334.
Legend: A score ranging from 4.21 to 5.00 was interpreted as very high or strongly positive (agree strongly, all
the time), 3.41 and 4.20 were categorized as high or positive (agree slightly, occasionally), 2.61 to 3.40 were
considered moderate or neutral (neutral, some), 1.81 to 2.60 were labeled as low or negative (disagree slightly,
rarely), and 1.00 and 1.80 were interpreted as very low or strongly negative (disagree strongly, never).
Safety. The research indicated a high or positive perception of the safety climate. Nurses generally concurred
that their perspectives on quality would be enacted, errors were addressed appropriately, and performance
feedback was given. The participants concurred that the culture promotes learning from errors, fosters comfort
in receiving treatment within the facility, and aligns leadership values with those of the staff. They remained
neutral regarding the ease of discussing mistakes.
This suggests a generally supportive culture, albeit with some hesitations regarding the open reporting of errors.
Clinical experience indicates that while most nurses are receptive to standard feedback and encouragement, they
often hesitate to report errors or near-misses. This reluctance is particularly pronounced when past incidents
were met with punitive responses rather than constructive learning opportunities. The ambiguous response
regarding error discussion suggests the presence of a safety culture; however, psychological safety for all
individuals has not yet been fully established. This finding indicates that nurse managers must actively endorse
non-punitive error reporting practices. Clinical errors ought to be addressed transparently as opportunities for
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learning instead of being perceived as personal shortcomings. Nurses, especially those who are newer to the
profession, require assurance that the safety concerns they express will lead to constructive changes rather than
blame. Spreitzer (1995) emphasized that a positive work environment fosters psychological empowerment by
valuing staff and promoting their independence. Kanter's (1977) Structural Empowerment Theory posits that the
availability of support and resources, including an open error-reporting system, enhances staff confidence. Van
Bogaert et al. (2016) identified a correlation between a positive safety culture and both nurse satisfaction and
patient safety outcomes.
Communication. Communication, in relation to local leadership and teamwork climate, received a high or
positive rating. Nurses agreed that management was approachable, offered consistent feedback, and articulated
expectations clearly. Teamwork was viewed positively, especially within units where disagreements were
resolved and inquiries were welcomed. Communication among units and upward reporting remained
problematic, with respondents showing indifference toward expressing concerns regarding patient care. The
findings suggest strong intra-team communication, while interdepartmental and hierarchical communication
appears less effective. Based on direct experience, a majority of nurses indicate that they receive support from
their teams; however, they exhibit hesitance in escalating issues beyond their immediate supervisors. Cross-
departmental communication often lacks structure, leading to misunderstandings and unresolved issues.
Improving collaboration among departments is essential. Leadership should establish regular cross-functional
meetings or feedback mechanisms that include staff nurses. Furthermore, establishing a culture of psychological
safety, in which nurses are encouraged and feel secure in voicing their concerns, is essential for both staff well-
being and patient outcomes. Arnesen-Trunzo (2015) and Bandari (2020) identified empowering communication
as essential for reducing conflict and fostering trust. In addition, Sexton et al. (2019) identified communication
and teamwork as predictors of safety culture and patient outcomes.
Operational Reliability. Operational Reliability was rated as high or positive by the respondents, with the sub-
factor Improvement Readiness (Learning Environment) receiving particularly favorable responses (mean =
4.03), while Burnout Climate and Personal Burnout and Work-Life Balance were rated moderately. This
suggests that while nurses recognized that their workplace supported learning and quality improvement, concerns
still remained regarding personal well-being and workload sustainability. The finding that operational reliability
is rated positively highlights the strength of the institution's systems and improvement culture, but it also
underscores a need to address personal sustainability. Effective operational reliability must balance consistency
in procedures with workforce well-being to ensure long-term excellence in nursing care and staff retention. A
high score in Improvement Readiness indicates that the work environment promotes learning from mistakes,
encourages feedback and suggestions from staff, and is proactive in addressing and fixing defects in workflow
or care processes. This reflects a learning-oriented culture, which is essential for healthcare organizations that
aim to maintain high standards of patient care while minimizing errors. According to Sexton et al. (2019),
operational reliability is strengthened when institutions adopt a systems-thinking approach, ensuring that
continuous improvement is embedded into daily practice. Furthermore, Adair et al. (2022) emphasized that
leadership involvement in protecting the learning environment is associated with lower burnout and improved
care outcomes.
However, the moderate ratings in burnout and work-life balance indicate that while systems for improvement
may be in place, the human cost of maintaining operational reliability may still be considerable. Nurses reported
experiencing fatigue, frustration, and emotional strain, which may reflect chronic understaffing, workload
pressures, or misaligned expectations. In terms of the dimension of improvement readiness (learning
environment), this was rated as high or positive. Respondents slightly agreed that the learning environment in
the work setting utilized input/suggestions from the people who work, integrated lessons learned from other
work settings, effectively fixed defects to improve the quality of what people do, allowed them to gain important
insights into what they do well and was protected by the local management. this outcome suggests that although
hospitals recognize the importance of learning and improvement, they are not sufficiently addressing the
challenges faced by individual nurses. Nurses may participate in improvement and feedback processes; however,
this involvement can detrimentally impact their personal energy, mental wellbeing, or time. Nurses often
participate in meetings and audits despite being emotionally and physically exhausted from their duties.
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This discovery necessitates a shift from system-centered to human-centered improvement models. Organizations
must prioritize rest, breaks, and workload monitoring alongside the implementation of quality programs to
prevent burnout. Sustainable care encompasses not only the restoration of processes but also the protection of
caregivers' well-being. Maslach and Leiter (2016) argued that burnout is not just an individual issue but a
systemic one and is closely linked to organizational structures and culture. Van Bogaert et al. (2013) also found
that operational stress without adequate recovery time can diminish psychological empowerment and
compromise patient safety.
Burnout Climate and Work life balance. In terms of the dimension of burnout climate and personal burnout
this was rated as moderate. Respondents slightly agreed that events in the work setting affected the lives of
people in an emotionally unhealthy way, that people in the work setting were burned out from their work, were
fatigued from their work, were working too hard on their jobs, and that events in the work setting affected their
lives in an emotionally unhealthy way. However, they were neutral on the statement that people in the work
setting were frustrated by their jobs. They felt burned out from their work, felt fatigued when they get up in the
morning and have to face another day on the job, felt frustrated by their jobs, and felt they were working too
hard on their job. Moreover, they were neutral on the statement that in the past month, their activities had been
restricted due to illness and had missed work.
The dimension of work-life balance was rated as moderate. Respondents believed at some point that they skipped
a meal, they ate a poorly balanced meal, they arrived home late from work, they had difficulty sleeping, they
slept less than five hours in a night, and that changed personal/family plans because of work. However, they
rarely worked through a day/shift without any breaks and felt frustrated by technology.
A depressing but little-known reality is conveyed by these unsatisfactory ratings: systematic overworking has
become the new standard. Although they continue to perform their duties, nurses are discreetly suffering from
emotional and physical strain. Observations reveal that employees frequently miss breaks, attempt to balance
family obligations, or accept these as "part of the job."
These warning indicators must be recognized and addressed by healthcare institutions. In order to retain nurses
and provide high-quality care, flexible scheduling, adequate staffing, and meal/rest safeguards are now
requirements rather than options. Emotional strain may be reduced by support systems like resilience training or
peer debriefing. Hardimansyah (2015) argued that if they are unable to function correctly, it will affect their
ability to perform their duties as employees. If the relationship between work and personal life is unequal, all
employee performance, motivation, and enthusiasm will be at risk. As it pertains to the productivity of employees
(Aoerora & Marpaung, 2020).
Engagement. Engagement was rated as moderate as all its dimensions were rated also moderate. This suggests
that while nurses did not express strong dissatisfaction, they also did not feel deeply engaged or committed to
their roles and workplace. A moderate level of engagement reflects neutral or cautiousness, indicating that nurses
may be performing their duties but are not highly motivated, emotionally invested, or connected to the
organization’s mission. In terms of growth opportunities, this was rated as moderate. Respondents were neutral
that there were opportunities for personal growth/development, they had the feeling that they can achieve
something, that there were opportunities for independent thought and action, there was freedom in carrying out
work activities, there was influence in the planning work activities, and there was influence in decisions about
work activity timelines. In terms of workload, this was rated as moderate. Respondents were neutral that there
was too much work to do, to work under time pressure, to attend to many things at the same time, to give
continuous attention to work, and to remember many things. In terms of advancement, this was rated as moderate.
Respondents were neutral on the fact that they can live comfortably on their pay, the organization pays good
salaries, they were paid enough for the work they do, they had opportunities to progress financially, they had
opportunities to advance through training courses, they had opportunities to be promoted, and they were satisfied
with their total benefits package.
In terms of participation in decision-making, this was rated as moderate. Respondents were neutral that the
decision making process was clear to them, it was clear to whom they should address specific problems, they
can discuss work problems with their direct supervisor/physician leadership, they can participate in decisions
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about the nature of their work, they had a direct influence on their organization’s decisions, and that the
organization utilized inputs from staff about technology initiatives. This suggests that while nurses may be
occasionally consulted or involved, they may not feel their contributions significantly shape policies or practices.
This aligns with Spreitzer's (1995) theory of psychological empowerment, which highlights influence and
autonomy as core components of motivation and engagement. When staff feel they have little control or say in
their work environment, their engagement naturally diminishes. In terms of job-related uncertainty, this was also
rated as moderate. Respondents were neutral that they felt certain that they will still be working in the
organization in one year’s time, felt certain that they will keep their current job in the next year, and felt certain
that they will keep the same function level as currently. The moderate ratings in workload and job-related
uncertainty further imply a sense of instability or stress, which can dampen emotional commitment to the
organization.
Thus, this data shows a productive but unengaged workforce. Many nurses appear emotionally detached or timid,
going about their daily job without much ownership or dedication. Nurses may wish to progress but are limited
by training, career stagnation, or unclear promotion paths, according to workplace observations. They will take
on several roles under time pressure out of necessity, not satisfaction. Discussions frequently reveal that financial
factors and sentiments of unappreciation over time weaken staff commitment. Nurses may also feel like
bystanders in organizational decisions due to neutral responses to decision-making and job security. This can
make them feel powerless when their ideas are ignored. In response to future intentions questions, many may
not be job looking but don't have strong employment attachments.
A moderate engagement rating poses a risk to staff retention and the quality of patient care. Nurses with partial
commitment exhibit increased vulnerability to burnout, errors, and emotional exhaustion. Healthcare facilities
must establish clearer channels for professional development, recognize accomplishments, and involve nurses
meaningfully in decision-making processes. Gokenbach and Drenkard (2011) noted that overwhelming
workloads and ambiguous job expectations contribute to burnout and disengagement among nurses. Moreover,
moderate scores on intentions to leave highlight an underlying hesitation to remain in their current roles, even if
not strongly felt yet. Respondents were neutral about them liking to find a better job and often thinking about
leaving their jobs. However, they slightly disagreed that they had plans to leave their jobs within one year.
Table 2 Psychological Empowerment of the Nurses
Dimensions
Mean score
SD
Interpretation
Meaning
4.53
1.23
High empowerment
Competence
4.44
1.24
Moderate empowerment
Self-determination
4.63
1.01
High empowerment
Impact
4.47
1.12
High empowerment
Grand Mean
4.52
0.98
High empowerment
Note. n=334.
Legend: scores ranging from 6.17 to 7.00 is extremely high empowerment (very strongly agree), 5.31 to 6.16 is
very high empowerment (strongly agree), 4.45 to 5.30 is high empowerment (agree), 3.59 to 4.44 is moderate
empowerment (neutral), 2.73 to 3.58 is low empowerment (disagree), 1.87 to 2.72 is very low empowerment
(strongly disagree), and 1.00 to 1.86 extremely low empowerment (very strongly disagree).
Overall, the respondents had high psychological empowerment. This means that nurses feel confident in their
ability to make choices and take action, and they have a strong sense of control over their lives and careers. It is
about believing their actions have a positive impact, feeling capable, and having a voice. This translates into
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motivated, involved, and productive nurses in the workplace. Contrary to the findings, the study of Al-Shomrani
et al. (2024) revealed that nurses with low psychological empowerment experienced reduced autonomy,
increased emotional exhaustion, and lower job satisfaction.
In terms of meaning, the respondents showed high levels of empowerment. They agreed that they were confident
in their abilities, found their work important, or had autonomy in how they performed tasks. This reflects a
connection between personal values and job responsibilities, which Spreitzer (1995) described as detrimental to
intrinsic motivation and job satisfaction. Studies such as Fragkos et al. (2020) also highlight that when nurses
do not find meaning in their work, their engagement and performance suffer significantly. In terms of
competence, they likewise reported moderate levels of empowerment, indicating a fair confidence in their impact
and control within the department. According to Thomas and Velthouse (1990), perceived competence is
essential for fostering motivation and proactive behavior. The findings are consistent with Van Bogaert et al.
(2016), who found that when nurses feel they lack influence and control, they are less likely to take initiative
and more prone to stress and dissatisfaction.
For self-determination, the respondents reported high levels of empowerment. They agreed with having full
decision-making freedom and they agreed regarding independence and skill mastery. This suggests a high sense
of autonomy, possibly abiding to organizational policies or rigid protocols. Skar (2010) emphasized that self-
determination is crucial in dynamic clinical settings, and without it, nurses may feel constrained in their
professional roles. Lastly, in terms of impact, respondents again reported high levels of empowerment. They felt
that their work was meaningful or that they had significant influence or confidence in their capabilities. This
aligns with Spreitzer and Doneson (2005), who asserted that a lack of perceived impact diminishes motivation
and reduces the sense of professional fulfillment. The findings also echo Taketomi et al. (2024), who concluded
that nurses in unsupportive environments often feel powerless and disconnected from organizational goals.
Table 3 Dimensions of Work Setting Predicting Psychological Empowerment
Variables
B
Std
Error
Beta
t
p
value
Decision
Interpretation
(Constant)
3.396
.541
6.276
.000
Safety climate
.058
.140
.034
.418
.677
Failed to Reject Ho
Not significant
Teamwork climate
.279
.127
.193
2.196
.029
Reject Ho
Significant
local leadership
-.080
.125
-.047
-.638
.524
Failed to Reject Ho
Not significant
improvement
readiness
-.122
.124
-.085
-.982
.327
Failed to Reject Ho
Not significant
Burnout climate and
personal burnout
.089
.077
.082
1.160
.247
Failed to Reject Ho
Not significant
Work-life balance
-.161
.083
-.132
-1.951
.052
Failed to Reject Ho
Not significant
Growth opportunities
.063
.130
.038
.486
.627
Failed to Reject Ho
Not significant
Workload
.013
.124
.008
.108
.914
Failed to Reject Ho
Not significant
Participation in
decision-making
-.451
.122
-.276
-3.701
.000
Reject Ho
Significant
Job-related
uncertainty
.467
.159
.261
2.936
.004
Reject Ho
Significant
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Advancement
.066
.094
.052
.708
.479
Failed to Reject Ho
Not significant
Intentions to leave
.074
.065
.071
1.141
.255
Failed to Reject Ho
Not significant
Legend: Significant if p value is < .05. Dependent variable: Psychological empowerment. If R-squared value <
0.3 is None or Very weak effect size, if R-squared value 0.3 < r < 0.5 is Weak or low effect size, if R-squared
value 0.5 < r < 0.7 is Moderate effect size, and if R-squared value r > 0.7 is Strong effect size.
The table shows that p values for the independent variables of teamwork climate, participation in decision-
making, and job-related uncertainty were lesser than the significant value of .05 which were interpreted as
significant which further means that teamwork climate, participation in decision-making, and job-related
uncertainty predicted psychological empowerment. Therefore, psychological empowerment is influenced by
teamwork climate, participation in decision-making, and job-related uncertainty. Looking at the table, the t
values for teamwork climate and job-related uncertainty were positive while for participation in decision-making
was negative. These findings indicated that the influence of teamwork climate and job-related uncertainty on
psychological empowerment were positive while the influence of participation in decision-making on
psychological empowerment was negative. A positive influence means that as teamwork climate and job-related
uncertainty increases it also increases psychological empowerment such that for every one unit increase in
teamwork climate and job-related uncertainty it results in a 2.196 and 2.936 increase in psychological
empowerment, respectively. Psychological empowerment increases when the teamwork climate improves
because effective collaboration fosters trust, communication, and mutual support—all of which are core
components of empowerment. As Van Bogaert et al. (2016) and Spreitzer (1995) emphasized, environments that
encourage team cohesion and open dialogue strengthen an individual's sense of meaning, competence, and
impact in their role. Moreover, Sexton et al. (2019) found that high-functioning teams promote psychological
safety, enabling nurses to express ideas and concerns without fear, which in turn boosts their sense of control
and autonomy.
Similarly, the positive association with job-related uncertainty may indicate that when nurses are more certain
about job stability (i.e., lower perceived uncertainty), their psychological empowerment increases. As described
by Taketomi et al. (2024), job stability supports a sense of control and confidence in the workplace, contributing
positively to empowerment dimensions such as competence and impact. Nurses who feel secure in their roles
are more likely to invest emotionally and cognitively in their work, increasing their sense of purpose and
influence.
On the other hand, a negative influence means that as participation in decision-making decreases, it results in a
3.701 increase in psychological empowerment. This counterintuitive result may reflect a disconnect between
token participation and actual influence. According to Spreitzer (1995), empowerment is not merely about being
involved in decisions but about feeling that one’s input is valued and acted upon. Brown (2002) and Deng &
Mao (2011) support the idea that poorly structured or unclear participatory processes can lead to frustration,
disillusionment, and a diminished sense of efficacy. When nurses are asked to participate without meaningful
outcomes or when decision-making is bureaucratic, it may create a sense of powerlessness rather than
empowerment. Thus, lower levels of superficial or ineffective participation may paradoxically lead to higher
empowerment if nurses can focus on areas where they have genuine autonomy and control. The model summary
revealed the following values: R = .339, R Square = .115, Adjusted R Square = .082, Std. Error of Estimate =
.93585, F = 3.484, Sig. = .000 Therefore, the regression model created is as follows:
Psychological Empowerment = 3.396 + 2.196 (teamwork climate) 3.701 (participation in decision-
making) + 2.936 (job-related uncertainty)
The equation reads that psychological empowerment is the result of the constant value of 3.396 plus 2.196 if
teamwork climate minus 3.701 of participation in decision-making plus 2.936 of job-related uncertainty. Based
on the model summary, the r squared value was .115 which indicates that the total variation in the psychological
empowerment can be explained by the independent variables of teamwork climate, participation in decision-
making, and job-related uncertainty. In this case, 11.50 percent can be explained which is very weak. This means
that the variable of teamwork climate, participation in decision-making, and job-related uncertainty predicting
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psychological empowerment has no effect. Thus, the regression model was also very weak. Based on the
significant value of .000, the regression model predicts the dependent variable significantly. The value was equal
to .000, and indicates that, overall, the regression model statistically significantly predicts the outcome variable
(i.e., it is a good fit for the data).
However, the p values for the independent variables of safety climate, local leadership, improvement readiness,
burnout climate and personal burnout, work-life balance, growth opportunities, workload, advancement, and
intentions to leave were greater than the significant value of .05 which were interpreted as not significant which
further means that they did not predict psychological empowerment. Therefore, the psychological empowerment
is not influenced by safety climate, local leadership, improvement readiness, burnout climate and personal
burnout, work-life balance, growth opportunities, workload, advancement, and intentions to leave. Whether
safety climate, local leadership, improvement readiness, burnout climate and personal burnout, work-life
balance, growth opportunities, workload, advancement, and intentions to leave is high or low, there can still be
a high level of psychological empowerment.
CONCLUSION AND RECOMMENDATIONS
Conclusion. Psychological empowerment among nurses is shaped by teamwork climate, decision-making
involvement, and job-related uncertainty. A generally positive work environment—especially in safety and
communication—nurses reported high psychological empowerment, particularly in meaning, self-determination,
and impact.
Only teamwork climate, participation in decision-making, and job-related ambiguity significantly predicted
psychological empowerment. While Kanter’s theory highlights the importance of structural factors, the findings
suggest that these alone are insufficient without being personally internalized. Spreitzer’s theory is more strongly
supported, emphasizing the role of psychological states in fostering true empowerment.
Ultimately, structural support must be paired with efforts that promote meaning, autonomy, and influence in
daily work. A Psychological Empowerment Encouragement Plan is therefore recommended, combining
structural changes with strategies to strengthen nurses' professional identity and intrinsic motivation.
Recommendations. Based on the findings of the study, the following recommendations are given:
Nursing Practice. Enhance collaboration and teamwork by fostering a positive teamwork climate within
hospital wards. Nurse managers must implement team-building strategies and promote a constructive work
environment to enhance interpersonal relationships among staff members. In addition, encourage shared
decision-making by involving staff nurses in clinical and operational decisions, thereby enhancing their sense of
independence and value in their roles.
Nursing Education. Incorporate principles of psychological empowerment into nursing education, especially
within clinical practicums, to enhance understanding of autonomy, competence, and impact in nursing practice.
Also, incorporate leadership and empowerment training into continuing professional development to enhance
nurses' confidence, self-determination, and decision-making skills. Utilize reflective practice and journaling to
encourage students and staff nurses to contemplate the significance and personal relevance of their work, thereby
improving the "meaning" component of psychological empowerment.
Nursing Policy. Promote structural empowerment policies that encompass adequate staffing levels, resource
availability, effective communication channels, and opportunities for career development. Implement nurse
governance guidelines to facilitate nurse participation in institutional and administrative committees and
decision-making processes. Thus, develop mental health and well-being programs aimed at addressing burnout
and promoting work-life balance, incorporating specific interventions to improve emotional climate and reduce
job uncertainty.
Nursing Research. Nursing research can further explore psychological empowerment across diverse healthcare
settings—such as public versus private hospitals and urban versus rural communities—by employing mixed
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methods to gain a comprehensive understanding of nurses' experiences. Future studies may also examine the
long-term effects of psychological empowerment enhancement initiatives, particularly their impact on nurse
retention, patient outcomes, and overall organizational effectiveness. Additionally, investigating the relationship
between demographic factors and perceived empowerment, specifically how age, years of experience, and
educational attainment shape nurses’ sense of empowerment can provide valuable insights for developing
targeted strategies to support and sustain an empowered nursing workforce.
The following are also suggested for future studies:
a. The Effect of Team-Based Interventions and Shared Decision-Making on the Psychological
Empowerment of Staff Nurses in Hospital Wards
b. Integrating Psychological Empowerment Concepts in Clinical Nursing Education: Effects on Student
Nurses’ Autonomy and Professional Identity
c. Evaluating the Impact of Structural Empowerment Policies on Nurse Well-Being, Burnout, and
Psychological Empowerment in Healthcare Institutions
Psychological Empowerment Enhancement Plan
Rationale
This plan is developed in response to the study's findings indicating that staff nurses exhibit low levels of
psychological empowerment, particularly in the areas of meaning, competence, and impact. Despite a
predominantly favorable work environment, significant predictors such as teamwork climate, decision-making
participation, and job-related uncertainty highlight the necessity for targeted interventions. This plan, informed
by Kanter's Structural Empowerment Theory and Spreitzer's Psychological Empowerment Theory, aims to
bridge the divide between structural support and individual empowerment to improve nurse motivation,
performance, and well-being.
General Objectives
The objective is to develop and execute a comprehensive intervention aimed at enhancing the psychological
empowerment of staff nurses by improving their perceptions of meaning, competence, self-determination, and
impact within their professional roles.
Specific Objectives:
1. The objective is to improve nurses' sense of meaning by aligning their roles with both organizational and
personal values via reflective workshops and recognition programs.
2. Enhancing nurses' competence through continuous professional development, mentorship, and skill-
building activities.
3. To promote self-determination by enabling nurses to participate in decision-making and gain increased
control over their schedules and work processes.
4. To strengthen nurses' sense of influence, it is essential to improve feedback mechanisms that clearly
demonstrate the direct impact of their activities on patient care and organizational success.
Areas of
Concern
Specific
Objectives
Activities
Persons
Responsible
Resources
Time Frame
Success
Indicators
The need to
further improve
the high or
To further
increase the
high or positive
work settings to
very high or
a.) Conduct
frequent Safety
and Teamwork
Nurse
Training
Materials
Every 2-3
months
Enhanced staff
ratings on
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positive work
setting
very positive
safety climate,
teamwork
climate, local
leadership,
improvement
readiness,
burnout climate
and personal
burnout.
To improve the
moderate levels
to very high or
very positive
work-life
balance, growth
opportunities,
workload,
participation in
decision-
making, job-
related
uncertainty,
advancement,
and intentions to
leave among
nurses.
Enhancement
Workshops
b.) Establish
monthly
leadership
meetings
between nurse
leaders and staff
Start a wellness
and stress
management
sessions.
c.) Implement a
Staff Suggestion
Box and Action
Board to offer
transparent
feedback on the
modifications
enacted.
HR Staff
Chief Nursing
Officer
- Health and
safety
policies,
procedures,
and training
manuals for
the
workplace
- Teamwork
and
emergency
response
role-
playing
exercises
- Example of
real-world
safety
incidents
and the
measures
taken by
successful
teams
- Safety
checks and
pamphlets
outlining
the ideals of
collaboratio
n
S.C.O.R.E.
factors in post-
intervention
surveys, going
from high to
very high.
A low
psychological
empowerment.
To improve the
psychological
empowerment
to very high in
terms of
meaning,
competence,
self-
determination,
and impact
among nurses.
Meaning: Hold
Workshops or
seminars when
nurses are urged
to consider how
their work is in
line with their
own and the
organization's
values,
considering the
experiences of
seasoned
nurses.
Nurse Educator
Journals
Reflection
Quarterly
In focus groups
or interviews,
nurses are more
explicit about
the connections
between their
work and their
personal and
professional
values.
Competence: To
improve
abilities and
confidence,
implement a
professional
development
program that
includes
frequent
trainings, role-
playing
activities, and
Clinical Nurse
Educator
Nurse Managers
Guidebooks
Modules
Monthly
Sessions
Follow-up
surveys
indicated an
increase in
"competence"
ratings,
correlating with
a higher number
of nurses
participating in
advanced roles
and training.
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peer
mentorship.
Self-
Determination:
Implement
flexible
scheduling and
initiate
"Empowerment
Dialogues"
wherein nurses
work together to
develop unit
protocols and
shift schedules.
Unit Heads
Scheduling
Office Nurse
Leaders
Meeting
templates
Every Month
Updates
Positive remarks
for participation
in shift planning
and flexible
schedule
Impact: Install
"Visible Impact
Boards" in
departments that
show metrics
like patient
happiness,
recovery, and
success stories
that are
specifically
linked to
nursing care.
Provide
feedback reports
that have an
impact.
Supervisors
Office Nurse
Infographics
Bulletin Board
Feedback forms
Every Month
Increased
perception of
impact in
questionnaire
responses
Staff report a
belief that their
work has a
significant
effect.
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