Empowerment Predicting Nurses' Work Motivation and Occupational Mental Health.

INTRODUCTION: Empowering nurses is essential for improving work outcomes, and understanding the role of structural and psychological empowerment in supporting nurses' work motivation and occupational mental health are essential to stimulate nurses' productivity and preserve their mental health.
OBJECTIVES: To evaluate nurses' perspectives about the levels of structural and psychological empowerment in their working areas. Additionally, to evaluate nurses' motivation and occupational mental health, and to predict the nurses' motivation and occupational mental health through structural and psychological empowerment.
METHODS: A descriptive correlational design and quota sampling were used. Two hundred registered nurses were recruited from two hospitals in Jordan. Data were collected using four valid and reliable self-report questionnaires.
RESULTS: Nurses who participated in this study were young and have an average total experience in nursing of fewer than 10 years. Nurses in this study reported a moderate level of structure empowerment and a low level of psychological empowerment. Significant positive relationships were documented between both structural, psychological empowerment, and nurses' work motivation (r = 0.85), (r = 0.83) respectively. A significant negative relationship found between both structural, psychological empowerment, and nurses' occupational mental health (r = -0.31), (r = -0.29) respectively.
CONCLUSIONS: The levels of nurses' work motivation and occupational mental health can be predicted through the levels of structural and psychological empowerment. The higher workplace empowerment was associated with increased work motivation, as well as reduced the feeling of occupational stress among nurses. Thus, administrators should invest in fostering structural and psychological empowerment in the work environment.

Introduction

Empowerment is a culture- bound expression, which reflects various meanings across the different cultures (Rashed & Fekry, 2015). Empowerment confirms that employees are partners in decision-making, providing high quality care, and achieving the agency's goals (Van Bogaert et al., 2016). Empowerment means freedom of choice, capability to act and ability to make the decisions (Skår, 2010). Kanter (1993) introduced Kanter's theory of structural empowerment, which defined power as the capacity to get things done, mobilize resources, and employ everything a person requires to accomplish one's objectives.

Empowerment could be structural or psychological. Structural empowerment is defined as workplace conditions that encourage optimal job performance and provide employees with access to the information, support, resources, and opportunities to learn and grow (Orgambídez-Ramos et al., 2017). Access to resources is an essential dimension of structural empowerment that offer materials, supplies, time, and financial funds for employees to carry out their work (Stewart et al., 2010). Access to opportunities is another dimension, which means the possibility to grow within the organization to increase knowledge and skills (Laschinger et al., 2010). Thus, employees need to get the necessary formal and informal information, they need support, feedback and guidance from superiors, colleagues and subordinates to accomplish their work efficiently (Wagner et al., 2010).

Psychological empowerment was defined as individual's cognitive state characterized by a sense of perceived control, competence and goal internalization (Oladipo, 2009). It has four dimensions; meaning, competence, self-determination, and impact. Meaning reflects “employee's values, beliefs, and behaviors that are congruent with workplace requirements”. Competence is “employee's beliefs about his ability to accomplish work tasks”, self-determination is “employee's sense of having options to start and carry out his own work”, and impact relates to “how much employee can influence their work” (Manojlovich, 2005; Spreitzer & Doneson, 2005, p. 314).

Motivation is a vital concept usually linked with empowerment (Gabra et al., 2019). Motivation is defined as “values-based, psycho-biologically stimulus-driven inner urge that activates and guides human behavior in response to self, others, and environment” (Moody & Pesut, 2006, p. 17). Higher motivation increases intrinsic satisfaction and leads to the intentional fulfillment of basic human drives, perceived needs, and desired goals (Moody & Pesut, 2006). A health system cannot achieve the desire outcomes without motivated heath care personnel, and motivation plays an important role in retaining health care personnel, increasing productivity of health care providers, and consequently improving patients’ outcomes (Gabra et al., 2019). Work motivation is one of the nurses’ job related outcomes, which can be improved and enhanced by the high level of structural empowerment (Cai et al., 2011).

Empowerment also has a positive impact on nurses’ occupational mental health (Read & Laschinger, 2015). It reduces job stress that is widely prevalent among nurses (Papathanasiou et al., 2014). It was documented previously that 27% of hospital workers complained from mental health problems such as anxiety, depression, and post-traumatic stress disorder (Tajvar et al., 2015). The prevalence of mental health problems were very common among nurses in hospitals, especially those who work in critical care units (Sharma et al., 2014).

Occupational mental health was defined as "a state of well-being in which an employee realizes his or her own abilities, can cope with the routine stresses, can work productively and fruitfully, and is able to make a contribution to his or her community" (Osifo, 2016, p. 64).

Review of Literature

Structural empowerment and its dimensions

According to Kanter (1993) employees can get access to the lines of power by formal and informal power. Formal power is derived from job characteristics like flexibility, creativity, and centrality to the organizational goals. While informal power is derived from social connections between peers, sponsors, bosses and subordinates (Orgambídez-Ramos & Borrego-Alés, 2014).

Structure empowerment consists of access to information, resources, and support. Information is the knowledge that is necessary to accomplish the tasks in a good way or knowledge about an organization in general. Access to resources means the ability to use materials, supplies and financial recourses that are needed to a achieve work demands. Access to support refers to positive feedback from superiors and freedom of employees in their work (Laschinger et al., 2010).

Structural empowerment influences nurses directly on nursing dimensions, and it plays an important role in nurses’ satisfaction and enhances the provision of high quality of patient care (Bawafaa et al., 2015). Additionally, structural empowerment and access to work recourses will create positive perceptions concerning workplace, enhance work satisfaction and enhance retention rate among newly graduated staff (Pineau Stam et al., 2015). Many studies investigated the relationship between structural empowerment and nurses’ job stress, feeling of exhaustion and burnout. Guo et al. (2016) investigated the relationship between structural empowerment, job stress and burnout among 1002 nurses working at tertiary-level hospitals in china. The researchers found significant correlation between structural empowerment and all dimensions of job stress and burnout. Another study conducted in Portuguese among nurses, emphasized that accesses to structural empowerment is negatively associated with the level of nurses burnout (Orgambídez-Ramos et al., 2017). It was documented that structural empowerment improves nurses’ satisfaction and their outcome and quality of care (Boamah et al., 2017; Kretzschmer et al., 2017).

Psychological empowerment and its dimensions

Spreitzer (1995) stated that psychological empowerment is characterized as a collection of four motivational agents; meaning, competency, self-determination, and impact. Wang and Liu (2015) emphasized that psychological empowerment positively affects work engagement and professional practice environment. Additionally, in a study conducted in four large university hospitals in China, researchers reported that psychological empowerment positively affected job engagement, and acted as a mediating factor on work environment and job engagement (Kuokkanen et al., 2016).

Psychological empowerment is also found to associate with nurses’ job satisfaction and affected nurses’ retirement rate (Ouyang et al., 2015). However, psychological empowerment alone did not act as mediator factor between structural empowerment and job satisfaction, but it worked together with structure empowerment and leader empowering behaviors to enhance nurse’ satisfaction and turnover (Dahinten et al., 2016). Additionally, there was negative correlation between both bullying and intent to leave and psychological empowerment among nurse leaders (Hampton & Rayens, 2019).

Studies from Jordan revealed that job satisfaction is significantly affected by psychological empowerment among health workers in private hospitals (Saif & Saleh, 2013). Psychological empowerment has serious and positive influence on safety, work performance, and decreases occupational accidents among intensive care unit nurses in Jordanian hospitals (Bsheish et al., 2019). Performance accountability has also moderate relationship with managers’ psychological empowerment (Mohseni, 2019).

Structural empowerment and psychological empowerment

DiNapoli et al. (2016) found that there were positive relationships between structural empowerment and psychological empowerment and staff engagement. Structural and psychological empowerment influences each other to decrease burnout syndrome and improves the work life quality among nurses (Nursalam et al., 2018). Availability and access to various organization opportunities enhance employees’ eligibility and competence to perform their tasks and increase self-determination (Latifa, 2017). Additionally, the empowerments in both structural and psychological domains had an essential role and affected positively the nurses’ intent to stay and negatively their burnout level (Meng et al., 2015).

Meng et al. (2016) identified the role of psychological empowerment as mediator factor between structural empowerment and burnout among nurses. In the same context, the structural empowerment and psychological empowerment had indirect effect on burnout moderated by hardiness (Ayala Calvo & García, 2018).

In another way, when nurses utilize structural empowerment component, they feel themselves important in their organization. In turn, this enhances work commitment, and increases trustworthiness with their leaders (Freire & Azevedo, 2015). Laschinger (2008) promoted the partnership between psychological and structural empowerment in order to improve organizational performance and suggested an expansion to the Kanter model incorporating psychological empowerment as a significant mediator.

Kundu et al. (2019) emphasized on the effect of structural empowerment on psychological empowerment positively by empowering a nurse leaders, and mediating effect on concept of work performance by empowering leadership behaviors among nurses. In the same context, structural empowerment and psychological empowerment have a direct effect on engagement and quality of nurses’ work (Fibriansari, 2018). Another study targeted emergency room nurses, and found clear improvement of clinical leadership behaviors through enhancement of structural and psychological empowerment (Connolly et al., 2018).

Motivation and its related factors

Work Motivation in nursing has an influence on job performance in nursing discipline (Budiawan et al., 2015). The extrinsic and intrinsic motivations were influenced by individual and hospital background as nurses’ age, duration of service, training and work orientation (Toode et al., 2015a). Additionally, there was relationship between motivation and managerial experience, income, job satisfaction, staff roles, and perception of work stress (Bodur & İnfal, 2015). Leadership styles influence nurses’ motivations (Trihastuti et al., 2016), and consequently motivation influence job satisfaction and patient safety (Toode et al., 2015b).

It is well documented that motivated nurses had better career adaptability, more staff optimism, and higher psychological wellbeing (Fang et al., 2018; Nwankwo et al., 2018).

Occupational mental health and its related factors

Throughout recent years, there has been increasing concern about the high prevalence of mental health problems among health care workers (Taghinejad et al., 2014). Tajvar et al. (2015) found that occupational stress had significant relationship with mental health among nurses. Mental health-related long-term sickness influenced psychological demands, role conflict, and harassment at the workplace among nurses and had relationship with job resources like social support at work, role clarity and fair leadership (Roelen et al., 2018). Based on the related literature, Ghawadra et al. (2019) estimated the prevalence of psychological distress among nurse as 41%, and the prevalence of stress, anxiety and depression were 14.4%, 39.3% and 18.8%, respectively. In another survey conducted in British hospitals, almost half of health care workers reported experiencing a mental distress (Sherring, 2019).

Occupational mental health has been linked to productivity and other desired organizational outcomes, such as commitment and satisfaction (Gulavani & Shinde, 2014; Klein et al., 2017). Several negative outcomes of occupational mental health were reported such as job tension, job fatigue, depression, and burnout (Lin et al., 2016; Taghinejad et al., 2014). In turn, Kuroki (2012) found some characteristic aspects that have affected occupational mental health, such as knowing and using organizational tools, receiving support from department manager, and availability of support to the mentally challenging workers. Moreover, work-life conflict, irregular work hours, and heavy work pressure was corresponding with higher levels of burnout among physicians and nurse practitioners (Kumar & Bhalla, 2019).

Sarafis et al. (2016) reported a positive relationship between occupational stress and nurses’ health-related quality of life, and then influenced patients’ outcomes. Additionally, the burnout is positively related to increased risk of post–traumatic stress disorder among nurses, and that will affect their mental health. Nurses’ mental health affected directly with their ability and level of occupational coping and self-efficacy within workplace (Fida et al., 2018).

A Jordanian study included nurses from two public hospitals, reported that 30% of nurses reported occupational stress. The study also reported negative association between occupational stress and organization commitment (Al-Hawajreh, 2011).

Empowerment and nurses’ motivation, and occupational mental health

Wing et al. (2015) studied the impact of structural empowerment on nurses’ mental health among 394 new graduate nurses and found that they had low mental health symptoms in the area with high level of structure empowerment. Additionally, the structural empowerment mediating authentic leadership and nurses’ relational social capital, which in the result had a negative effect on nurses’ mental health symptoms and a positive effect on nurses’ job satisfaction (Read & Laschinger, 2015). Additionally, Özbaş and Tel (2016) emphasized the effect of psychological empowerment on occupational stress, and burnout among oncology nurse, by comparing between two groups of nurses, one group attended psychological empowerment course, and the other group was not involved in the course. In accordance with the aforementioned study, the psychological empowerment directly and indirectly affected the nurses’ self-efficacy, burnout, individual performance, job satisfaction, and emotional intelligence (Indrus et al., 2015).

Lautizi et al. (2009), discussed the effect of workplace empowerment on nurses’ occupational mental health and work effectiveness. The results revealed that empowering nurses’ work environment would reduce stress level and enhance nurses’ mental health. Studies also indicated that nurses’ innovative behaviors have a relationship with career success and self–efficacy, which in turn played a mediating role between structural empowerment and career success; and the structural empowerment is positively associated with innovative behavior and career success (Dan et al., 2018).

Moreover, self-efficacy partially mediated the relationship between structural empowerment and professional nursing practice, and the leadership behavior-moderating factor between structural empowerment and professional nursing practice (Manojlovich, 2005). Similar results were reported by the study that was conducted in Minia University hospital in Egypt, and reported a positive relationship between empowerment and motivation among nurses (Gabra et al., 2019). Rashidazar et al. (2018) also found that the structural empowerment has inverse relationship with job stress and burnout. The results also identified that motivation among nurses was influenced positively by leader self-efficacy, and motivation has a real relation with staff aspirations (Cziraki et al., 2018). In addition to that, psychological empowerment and structural empowerment influence the work safety behavior and occupational mental health among nurses (Yıldız et al., 2018).

In Jordan, very few studies could be found about investigating the relationships between structural, psychological empowerment and work motivation, as well as occupational mental health among nurse. The current study might help stakeholders in health organizations to understand the role of empowerment in enhancing nurses’ motivation and occupational mental health. Specifically, findings of this study will clarify the role of structural and psychological empowerment in supporting nurses’ motivation and occupational mental health. Consequently, this might help decision makers to improve work place to stimulate nurses’ productivity, professionalism, and preserve their mental health.

The aims of the study were to evaluate nurses’ perception about the levels of structural and psychological empowerment in their working areas. To evaluate nurses’ motivation and occupational mental health. Additionally, to predict the registered nurses’ motivation and occupational mental health through structural and psychological empowerment.

The following research questions were answered in the current study:

What are the levels of structural and psychological empowerment as perceived by nurses?

What are the levels of work motivation and occupational mental health among nurses?

Are there association between structural, psychological empowerment, work motivation, and nurses’ occupational mental health?

Do nurses who perceive higher structural empowerment exhibit higher (or lower) levels of work motivation and occupational mental health than nurses who do not?

Do nurses who perceive higher psychological empowerment exhibit higher (or lower) levels of work motivation and occupational mental health than nurses who do not?

Methods

The study employed a descriptive correlational design. The study was conducted in two hospitals have similar work environment in the Jordanian capital city of Amman.

Nurses included in the study were being registered nurses, working in the hospital for at least one year, free from any psychiatric illness and did not experience any major harmful emotional or psychologically events like death of a close relative or divorce within one month from the date of data collection. Nurses working as administrators and educators were excluded from the study.

Sampling and Data Collection

To improve the representativeness of the accessible population, and to reduce sampling bias, this study used quota-sampling method. A quota sampling technique was applied in each target hospital. A specific number of nurses who met the inclusion criteria were recruited from each unit in the two hospitals.

The calculation of the required sample size was done based on the formula proposed by Tabachnick and fidell for the regression analyses (104 + 8 * number of explanatory variables), revealed that for two explanatory variables, the minimum required sample size is120 subjects (Tabachnick et al., 2007).

Pilot Study

A pilot study was conducted to check the feasibility of the study questionnaires and to evaluate the recruitment process. The pilot study was conducted in the two hospitals using the same inclusion criteria and included about 10% of the study sample, and that was not included in the total study sample.

Measurements

The conditions for work effectiveness questionnaire (CWEQ-Ii)

This questionnaire measures the six components of structural empowerment through 21 items rated on a five-point Likert scale ranging from 1 (none) to 5 (a lot). The total structural empowerment score range from 6 to 30; score from 6 to 13 indicate low empowerment, 14 to 22 indicate moderate empowerment, and 23 to 30 indicate high empowerment (Laschinger, 2013).

Construct validity and internal consistency reliability for the CWEQ-II has been assessed and established (Laschinger et al., 2001). In the current study, the Cronbach's alpha coefficients for the total CWEQ-II was 0.97.

The psychological empowerment questionnaire

This questionnaire consists of four subscales that are meaning, competence, self-determination, and impact. Each subscale consists of 3 items with a total of 12 items. Each item rated on a five-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). The total score range from 12 to 60, and the subscales’ total score is from 3 to 15, and the higher score reflects higher psychological empowerment (Spreitzer, 1995).

Scale's construct validity was assessed and supported, and the Cronbach's alpha coefficients for the overall scale was 0.72, and for the subscales were ranged from 0.73 to 0.88 (Spreitzer, 1995). In the current study, Cronbach's alpha coefficients for the four subscales ranged from 0.85 to 0.88, and for the total scale was 0.96.

Work motivation scale

Multidimensional work Motivation Scale (MWMS) was used to measure the work motivation among nurses. This scale reflects the two types of motivation: intrinsic work motivation and extrinsic work motivation.

The extrinsic work motivation is the first dimension reflected through four subscales that have 12 items divided on: external regulation consists of 3 items, interjected regulation consists of 4 items, identified regulation consists of 3 items, and motivation which consists of 3 items. Each item asks participants to determine one of seven possible levels from 1 (not at all) to 7 (exactly) (Gagné et al., 2010).

The intrinsic Job Motivation is the second dimension that reflected through six items, that ask participants to determent a one choice from the scale that offer choices from 1 (strongly disagree) to 7 (strongly agree) (Warr et al., 1979).

The range of MWMS scores is from 19 to 133. The scores of 19 to 57 indicates a motivation, 58 to 95 moderate motivation, and 96 to 133 indicates motivation (Gagné et al., 2010). Previous studies supported the validity of MWMS, and the Cronbach's alpha coefficients for the scale was 0.87, and for the subscales were ranged from 0.69 to 0.89 (Gagné et al., 2010), and Cronbach's alpha in the current study for the subscales ranged from 0.7 to 0.82, and for the total scale was 0.87.

Mental health professionals stress scale (MHPSS)

This is a self-report scale used extensively to identify sources of stress and reflects the mental health of nurses and health care workers (Cushway et al., 1996). This scale consists of 42-items rated on a four-point Likert scale ranging from 0 (doesn't apply to me) to 3 (does apply to me), that represent seven subscales; workload consists of 6 items, client-related difficulties consists of 6 items, organizational structure and processes consists of 6 items, relationships and conflicts with other professionals consists of 6 items, lack of resources consists of 6 items, professional self-doubt consists of 6 items and homework conflict consists of 6 items. The MHPSS total score obtained by calculate the mean item score for each subscale, rather than the total subscale score, where the higher scores indicate higher levels of self-reported stress (Cushway et al., 1996).

Face, content, and concurrent validity were all evaluated and supported by the scale developer, and the Cronbach's alpha for the whole scale was 0.94 (Cushway et al., 1996). The Cronbach's alpha in the current study for the total scale was 0.86.

Data Analysis

The data was analyzed using IBM SPSS version 23. Descriptive statistics were used to describe the sample's socio-demographics, as well as to describe the levels of outcome variables (structural, psychological empowerment, work motivation and nurses’ occupational mental health). Association between the study main outcome variables were tested by Pearson's correlation coefficients.

Standardized linear regression was used to predict the levels of motivation and occupational mental health among nurses through structural and psychological empowerment. Few missing data were found at random sequence, and replaced by the mean of the related scores. Assumptions of the parametric tests were tested and ensured, and results were considered statistically significant at p > .05.

Results

Two hundred nurses participated in the study, and the majority of them were female 60.5%, married 53.5%, and work in medical surgical floors 32.5% (Table 1).

Table 1.

Characteristics of the Sample (n = 200).

Variables		% (n)
Gender	Male	39.5 (79)
	Female	60.5 (121)
Marital status	Single	46.5 (93)
	Married	53.5 (107)
Monthly income	≤ 320$	21.5 (43)
	321 to 570$	53.0 (106)
	> 570$	25.5 (51)
Area of work	Medical/Surgical floors	32.5 (65)
	Emergency room	7.5 (15)
	Out patients clinics	25.0 (50)
	Operation room	9.0 (18)
	Critical care units	20.5 (41)
	Pediatrics units	5.5 (11)

Participants’ ages ranged between 23 and 51 years old, with an average 30.3 (SD = 5.52), average years of experience in nursing profession was 7.7 (SD = 5.57), and average years of experience in the current hospital was 6.42 (SD = 5.04).

Levels of Structural and Psychological Empowerment

The average of total structural empowerment score was 17.26 (SD = 6.15). As presented in Table 2, the highest dimension of structural empowerment as perceived by nurses was the informal power (µ = 3.03, SD = 1.18), whereas formal power perceived as the least dimension (µ = 2.81, SD = 1.05).

Table 2.

Sub-Dimensions of the Outcome Variables.

Variables	Sub-dimensions	Mean	SD ±
	Opportunity	2.81	1.14
	Access to information	2.91	1.18
structural empowerment	Support	2.87	1.16
	Resources	2.85	1.11
	Formal power	2.80	1.06
	Informal power	3.02	1.18
	Meaning	4.58	1.35
psychological empowerment	Competency	4.59	1.36
	Impact	4.35	1.26
	Self-determination	4.31	1.40
	Motivation	15.08	4.04
	Extrinsic regulation -social	12.84	2.53
Work Motivation	Extrinsic regulation -material	12.48	3.26
	Introjected regulation	18.65	4.51
	Identified regulation	13.20	4.03
	Intrinsic motivation	15.08	3.91
	Client related difficulties	1.36	0.50
	Organization structure	1.63	0.61
	Relationships with professional	1.31	0.51
Occupational mental health	Lack of resources	1.35	0.61
	Professional self-doubt	1.23	0.52
	Homework conflict	1.36	0.47
	Workload	1.92	0.42

The average of total psychological empowerment score was (4.46, SD = 1.24). As presented in (Table 2), the highest dimension of psychological empowerment as perceived by nurses was the competency (µ = 4.59, SD = 1.37), whereas, self-determination perceived was the least dimension (µ = 4.31, SD = 1.40).

Levels of Work Motivation and Occupational Mental Health

The average of total work motivation score was 85.33 (SD = 13.85). As presented in Table 2, the highest dimension of work motivation as perceived by nurses was the introjected regulation (µ = 18.65, SD = 4.51), whereas extrinsic regulation-material perceived as the least dimension (µ = 12.48, SD = 3.26).

The average of total occupational mental health score was 10.16 (SD = 2.49). As presented in Table 2, the highest stressful dimension of occupational mental health as perceived by nurses was the workload (µ = 1.92, SD = 0.42), whereas, professional self-doubt was perceived as the least dimension (µ = 1.23, SD = 0.51).

Association Between the Outcome Variables

The relationships between structural and psychological empowerment and nurses’ work motivation were examined using the Pearson's correlation coefficient. Results showed statistically significant strong and positive association between structural empowerment and work motivation (r = 0.85, p < .001), and (r2 = 0.73). Psychological empowerment also had a statistically significant strong association with work motivation (r = 0.83, p < .001), (r2 = 0.68). Both structural empowerment and psychological empowerment were significantly associated with a strong positive relationship (r = 0.899, p < .001).

The relationships between structural and psychological empowerment and nurses’ occupational mental health were examined using the Pearson's correlation coefficient. Results showed a statistically significant moderate negative association between structural empowerment and occupational mental health (r = −0.301, p < .001), and (r2 = 0.09). Psychological empowerment also had a statistically significant negative association with occupational mental health (r = - 0.29, p < .001), (r2 = 0.08).

Predicating the Work Motivation

The regression model showed that structural empowerment can predict the work motivation (F(1,199) = 519.31, p < .001). The slope of the regression line was 1.914, showing that for every one unit increase in structural empowerment, the work motivation will increase by 1.914, and the standardized coefficients (Beta = 0.851, 95% CI = 1.748–2.080) (Table 3).

Table 3.

Predicting Work Motivation.

Predictors	B	Std. Error	Beta	t	Sig.	95% CI for B
						Lower	Upper
Structural empowerment	1.91	0.08	0.85	22.78	0.00	1.74	2.08
Psychological empowerment	9.21	0.443	0.828	20.77	0.00	8.33	10.08

The regression model showed that psychological empowerment can predict the work motivation (F(1,199) = 431.66, p < .001). The slope of the regression line was 9.21, showing that for every one unit increase in psychological empowerment, the work motivation will increase by 9.21, and the standardized coefficients (Beta = 0.828, 95% CI = 8.33–10.08) (Table 3).

Predicating Occupational Mental Health

The regression model showed that structural empowerment can predict the occupational mental health (F(1,199) = 19.96, P < .001). The slope of the regression line was −0.123, showing that for every one unit increase in structural empowerment, the occupational mental health score will decrease by −0.123 and the standardized coefficients (Beta = −0.303, 95% CI = −0.17 to 0.06) (Table 4).

Table 4.

Predicating the Occupational Mental Health.

Predictors	B	Std. Error	Beta	t	Sig.	95% CI for B
						Lower	Upper
Structural empowerment	−0.12	0.027	−0.303	−4.46	0.00	−0.17	−0.06
Psychological empowerment	−0.57	0.13	−0.288	−4.23	0.000	−0.84	−0.31

The regression model showed that psychological empowerment can predict the occupational mental health F(1,199) = 17, P < .001. The slope of the regression line was −0.578, showing that for every one unit increase in psychological empowerment, the occupational mental health will decrease by −0.578, and the standardized coefficients (Beta = −0.288, 95% CI = −0.84 to 0.31) (Table 4).

Discussion

Nurses participated in this study reported a moderate level of structure empowerment. Consistent with several previous studies (Liao & Liu, 2016; Pineau Stam et al., 2015), findings indicated a good level of nurses’ access to the organization structural recourses, information, and indicated that nurses have acceptable degree of support from leaders and pears in the organization. This result could be related to the settings where the study was conducted, in which both are accredited hospitals, and one of them is a magnet certified hospital, which stresses on empowering the work environment and staff.

Concerning the psychological empowerment, this study reported a low level. This result indicates that nurses perceived themselves as low empowered and not comfortable with their work environment .This might be related to the organization's restrictions, or the high level of workload. A possible explanation is that nurses are working in health care system that is dominated by physicians which reduces nurses’ autonomy, and consequently their perception about psychological empowerment, Wang and Liu (2015) emphasized that the psychological empowerment positively affects the work engagement and professional practice environment. Additionally, in a study conducted in four large university hospitals in China, researchers reported that psychological empowerment positively affected job engagement, and acted as mediating factor on work environment and job engagement (Kuokkanen et al., 2016).

This is inconsistent with a previous Jordanian study that reported high level of psychological empowerment among nurses in private hospitals (Saif & Saleh, 2013). The inconsistency reported here might be related to the differences between the two samples, in which most of their nurses have long experience (more than 15 years), and concomitantly they occupied administrative positions in their working settings. Conversely, the majority of nurses in the current study were on direct patient care. Moreover, 50% of nurses in the current study are working in a specialized oncology center, where patients suffer from the disease consequences, and nurses dealing more with the end stage cases, and dying patients (Browning, 2013).

Structural, Psychological Empowerment and Motivation

Results revealed a significant strong positive association between both the structural and psychological empowerment with work motivation among nurses. This reflects that nurses’ work motivation level will be enhanced with feeling of empowerment. This finding is consistent with Kanter’s (1993) theory which stated that work motivation is a key product of the structural empowerment, and access to information and knowledge in the organization will empower nurses to make care related decisions, and that will enhance nurses’ autonomy, and consequently being more motivated. Similarly, Klein et al. (2017) reported, that lack of transmission of important information, as well as differences about the decision-making process between physicians and nurses were sources of psychological distress and dissatisfaction for nurses.

Thus to achieve high quality of care and to enhance productivity, the organization should care for their employees through creating internal opportunity, accessing organization's recourses and information, training and education, and adapting a reward and intensive system. Consequently, this will enhance motivation level among nurses, and they will be motivated, feel more satisfied, and have higher performance and productivity (Aly & El-Shanawany, 2016). Similarly, previous studies reported association between structural, psychological empowerment and motivation (Gabra et al., 2019; Knol & Van Linge, 2009).

Structural, Psychological Empowerment and Occupational Mental Health

Both structural and psychological empowerments were negatively associated with occupational mental health. Results indicated that higher workplace empowerment is associated with reducing feeling of occupational stress among nurses. The reason of such association might be related to the impact of feeling of being appreciated by the work place. Providing nurses with an access to information, opportunities and resources will decrease level of occupational stress.

The study findings supported the role of structural and psychological empowerment in improving nurses’ sense of empowerment to enhance occupational mental health, and reduce stress. If nurses are unable to manage daily stress, they will experience physical and mental health symptoms as anxiety, depression, and somatic disorders (Khamisa et al., 2013). Additionally, feeling of powerlessness in workplace will increase internal senses of inefficient, obstructed, and reduced job satisfaction, reduced job effectiveness, increased levels of burnout, and intensify feelings to self-resignation from work (Eo et al., 2014). Wing et al. (2015) reported similar results and stated that ensuring the structural empowerment in the hospital setting is associated with lower mental health symptoms among nurses. Another study also supported the current findings, in which, it reported that occupational stress and burnout decreased with increasing the psychological empowerment at workplace (Wagner et al., 2010).

Strengths and Limitations

The findings of the study could assist in supporting the limited evidence on the impact of structural, psychological empowerment on work motivation and occupational mental health in Jordan. Using quote sampling technique improved representation and reduced the sampling errors.

Our study also had some limitations; using self-administered questionnaires might introduce some response set biases. Collecting data from only two hospitals and employing the non-probability sampling may limit the generalizability of the results.

Implications for Practice

The findings of this study pointed to several strategies that nurse managers and leaders can use to increase work motivation and decrease nurses’ occupational stress: such as creating a work environment that encourages nurses’ participation in decision-making processes, enhances work environment, increases internal opportunities, adapts a reward and incentive system, and offer a better quality of work-life. In conclusion, healthcare organizations are invited to improve nurses’ workplace conditions in order to generate empowered and motivated healthy nurses. This could be achieved through:

Supporting an empowered environment in hospitals, through facilitating access to resources and information necessary to nurses.

Creating opportunities and helping nurses increase their impact on work site to increase nurses’ work motivation.

Administrators should plan to help nurses keep psychological stability, because optimal emotional health among nurses will be reflected in better performance.

Stakeholders should care for their nurses and train them on problem solving and conflict resolution techniques, and decrease nurses’ workload.

Hospitals should create a fair rewarding and incentive systems for nurses to enhance nurses’ motivation level in work.

Organizational cultural should be directed toward creating motivation tools, and adapting stress management strategies.

Conclusions

Structural and psychological empowerments were strongly associated with nurses’ work motivation as well as occupational mental health. The higher workplace empowerment was associated with increasing work motivation, as well as reducing the feeling of occupational stress among nurses. Findings provided evidence on the possible benefits of adopting structural, psychological empowerment on improving the nursing work motivation and strategies to decrease stress and work pressure in work environment and establishing empowerment structures to enhance nurses’ involvement and participation in decision pertaining to their practice.

Supporting structural and psychological empowerment in the workplace will enhance motivation and improve nurses’ occupational mental health. Thus, administrators should invest in fostering the structural and psychological empowerment in the work environment.