ABSTRACT
This study aims to compare the differences in professional environment, job characteristics, and feelings of powerlessness between nurses and nurse aides (NAs) in residential long‐term care institutions, and to analyze the predictors of powerlessness. This study employed a comparative and correlational design, utilizing convenience sampling. Participants were recruited from 24 residential long‐term care institutions in central Taiwan between April 2023 and March 2024. The research tools included a Practice Environment Survey Scale, a Work Design Questionnaire, and a Powerlessness Scale. A total of 338 participants (156 nurses and 182 NAs) took part in this study. Both nurses and NAs reported moderate to low levels of powerlessness, with average scores of 42.18 and 37.07, respectively. However, nurses experienced more powerlessness than NAs (t = 3.046, p = 0.003). Hierarchical regression analysis indicated that professional environment (β = −0.381, p < 0.01) and job characteristics (β = −0.285, p = 0.005) were significant predictors of powerlessness among nurses, explaining 41.7% of the variance. In contrast, the only predictor of powerlessness for NAs was the professional environment (β = −0.695, p < 0.001), which explained 42.4% of the variance.
Keywords: job characteristics, long‐term care, powerlessness, practice environment
Summary.
This study provides insights into the differences in professional environment, job characteristics, and feelings of powerlessness between nurses and nurse aides in residential long‐term care institutions, supporting positive practice environment improvement.
The findings support that practice environment and job characteristics are significant predictors of nurses' feelings of powerlessness in residential long‐term care institutions.
The feeling of powerlessness among nurse aides was most strongly influenced by their satisfaction with the practice environment.
Abbreviations
- CVI
content validity index
- ICN
International Council of Nurses
- NAs
nurse aides
1. Introduction
Nurses and nurse aides (NAs) are vital human resources in long‐term care. Previous studies have shown that a high turnover rate of long‐term care staff leads to a decline in the quality of care and an increase in the rate of unplanned transfers of patients to acute care hospitals (Gandhi et al. 2021; Krein et al. 2022). Therefore, empowering and retaining human resources in residential long‐term care institutions is an important goal.
The practice environment and job characteristics are major influences on how nurses and NAs view their occupations. The practice environment consists of interactions among doctors, nurses, NAs, and caretakers, nurses and NAs' relationship with the patients, the resources available to the staff, and expectations of job performance. Moreover, patients in residential long‐term care institutions suffer from disabilities and multiple chronic diseases (Berger et al. 2025); therefore, the job characteristics of nurses and NAs become increasingly diverse, and the care tasks may differ. Previous studies have highlighted that staff working in long‐term care institutions may face a sense of powerlessness; however, there is a lack of quantitative research on this subject (Berglund et al. 2015; Young et al. 2017). In addition, Taiwanese culture differs from Western culture and is influenced by a patriarchal society. The authority in the organizational hierarchy of the medical system may lead to different views on work identity (Chang 2022; Lee 2023). Therefore, given the potentially reciprocal relationship between practice environment, job characteristics, and powerlessness, it is crucial to explore the perspectives of nurses and NAs who work under challenging long‐term care conditions.
2. Background
In 2007, the International Council of Nurses (ICN) advocated for a positive practice environment, defining it as a workplace that can cultivate and attract excellent and qualified nursing talent (ICN 2007, 2014). Such initiatives have gradually been accepted by the global nursing community and have brought significant improvements that benefit organizations, patients, and nurses (Dans and Lundmark 2019). However, faced with the complexity of the medical environment (e.g., the diversity of medical monitoring devices and high‐tech equipment) and diseases (e.g., the comorbidity of multiple chronic diseases), scholars have pointed out that nurses feel overwhelmed, exhausted, stressed, and powerless because of rapid and continuous changes in the workplace (Beaulieu et al. 2023; Mohammadi et al. 2021). Although these situations occur in hospitals, patients in long‐term care institutions often come from hospitals, and therefore, staff may initially face comparable situations. However, further research is needed to investigate the above.
In addition, regarding the practice environment of long‐term care institutions, Eltaybani et al. (2018) found that the reasons nurses choose long‐term care institutions, such as good working atmosphere, interest in elderly care, high salary, work engagement, educational opportunities, and support from nursing managers, were important factors in their willingness to stay. In contrast, willingness to stay was negatively correlated with emotional exhaustion. Lee (2022) conducted a systematic review of nursing home nurses' turnover intentions. The results showed that job satisfaction was the most important determinant of nurses' turnover intentions and suggested measures such as increasing salaries and improving the working environment to improve nurses' job satisfaction.
In addition, Wang et al. (2024) conducted an integrative literature review on the factors associated with the retention of staff in long‐term care institutions, including and summarizing the findings of eight studies; they proposed that work stress and burnout can cause staff to lose their enthusiasm, and environmental conditions in the workplace are considered important factors in the staff's willingness to stay. A positive working environment in long‐term care institutions is significantly associated with job satisfaction and willingness to stay, whereas emotional exhaustion prompts staff to leave the long‐term care system.
Hackman and Oldham's (1975) Job Characteristics Model related five core job characteristics, three critical psychological states, and on‐the‐job outcomes. Job characteristics refer to job‐related attributes or factors, including task variety, autonomy, identity, significance, and feedback. These job characteristics produce three psychological states, among which task variety, identity, and significance generate the experience of work meaningfulness. Autonomy produces a sense of responsibility for work results. Feedback leads to knowledge of the actual results of activities (Hackman and Oldham 1975; Pai et al. 2018). Job characteristics include various attributes related to psychological states and further influence work outcomes (e.g., work satisfaction, performance, and low absenteeism and turnover; Hackman and Oldham 1975).
Othman and Nasurdin (2019) investigated the job characteristics and engagement of 856 hospital nurses and found that job autonomy, feedback, identity, and significance were positively correlated with job engagement; however, task diversity was not. Chun and Cho (2018) also proposed that “task variety” and “job autonomy” in nurses' job characteristics are positively correlated with turnover intention, whereas job satisfaction is most correlated with task integrity and job autonomy. These studies emphasize the relevance of job characteristics to job engagement and retention; however, the research focused on hospital nurses. For long‐term care institutions, we found only one survey on the job characteristics of care workers (Hyun 2024). Hyun (2024) confirmed that the more positive the job characteristics (e.g., diversity, identity, and autonomy), the better the job performance of care workers.
As the literature mentioned above demonstrated, job characteristics that correlate with satisfaction and the improved performance of nurses and NAs have been identified as autonomy, significance, identity, feedback, and diversity. Research has also shown the opposite: long‐term NAs feel powerless, believing that their care work will not have a significant impact on residents' health outcomes, mainly because their job characteristics lack significance, feedback, and autonomy (Berglund et al. 2015; Young et al. 2017).
Yeh and Maa (2002) defined powerlessness as a sense of the inability to influence outcomes and control situations, whereas the North American Nursing Diagnosis Association (NANDA) defined powerlessness as an individual's “lack of control over a situation, including the feeling that one's actions cannot significantly affect the outcomes.” Its defining characteristics include alienation, frustration over not being able to perform past activities, dependence, inadequate involvement in care, depression, and lack of control (Phelps 2022). Powerlessness refers to the psychological feeling that an individual cannot exert their abilities or control a situation.
Swoboda et al. (2020) conducted an integrative literature review and suggested that nurses feel powerless to solve certain primary problems in organizations, such as insufficient staff, time, and equipment, which prevent them from providing individual care needs and make them feel powerless about their work environments. Afshani et al. (2019) found that nurses' sense of powerlessness sometimes stems from dissatisfaction with doctors' treatments, economic conditions, and high patient turnover. Other causes include care of patients beyond their control, lack of resources, and insufficient teamwork. George et al. (2023) pointed out that poor communication between nurses and physicians made them feel a lack of respect and that their concerns about patients were ignored, exacerbating their feelings of powerlessness. These empirical studies mainly focused on investigations of professional nursing environments in acute medical units. However, hospitals and long‐term care institutions have institutional structures that are nearly similar, whereby doctors, nurses, and NAs are the main human resources.
From our literature review, we realized that, in recent years, human resources in long‐term care institutions have received attention, and research has gradually increased. However, each study explored the issue from a different perspective, and the research failed to address whether the practice environment and job characteristics of nurses and NAs in long‐term care institutions were associated with their feelings of powerlessness. Therefore, the purpose of this study was to explore the relationship between the working environment, job characteristics, and powerlessness among nurses and NAs in residential long‐term care institutions and to compare and analyze the predictive factors of powerlessness among the two groups. To that end, our study proposed the following research hypotheses:
Hypothesis 1
There is a significant difference in feelings of powerlessness between nurses and nurse aides (NAs).
Hypothesis 2
There are significant differences between nurses and NAs in their perceptions of the current state of their practice environments.
Hypothesis 3
There are significant differences in job characteristics between nurses and NAs.
Hypothesis 4
Nurses' perceptions of their practice environments and job characteristics significantly predict their feelings of powerlessness.
Hypothesis 5
NAs' perceptions of their practice environments and job characteristics significantly predict their feelings of powerlessness.
We hope that the research findings can serve as an empirical basis for the future development of interventions aimed at reducing powerlessness among nurses and NAs in long‐term care institutions, so that the vital human resources of long‐term care can be empowered and retained.
3. Methods
3.1. Study Design and Participants
This study adopted a correlational research design and convenience sampling, targeting nurses and NAs in 24 residential long‐term care service institutions in central Taiwan. The inclusion criterion for nurses and NAs was full‐time employment for more than 3 months. Part‐time nurses and NAs were excluded.
The sample size was estimated using G Power 3.1.9.4 statistical software, and an independent t‐test (two groups) was used. Based on the results of a study conducted by Chun and Cho (2018), the effect size was set to 0.5 for the explanatory power of nurses' job characteristics on intrinsic satisfaction. The required sample size was at least 64 participants in each group. In addition, the effect size was set to medium using linear regression analysis, and the sample required 131 participants. Considering that the sample may have been incomplete, thereby resulting in a 20% loss, a sample size of 157 participants was ultimately required. A total of 402 questionnaires were sent, and 338 valid questionnaires were collected, with a response rate of 84.08%. The sample included 156 nurses and 182 NAs; thus, the sample size was sufficient to perform regression analysis.
3.2. Measurement
The questionnaires included a demographic questionnaire, a Practice Environment Survey Scale, a Work Design Questionnaire, and a Powerlessness Scale. All scales were reviewed by three experts, and the content validity index (CVI) reached above 0.89.
3.2.1. Demographic Questionnaire
The items included age, gender, years of work experience, years of long‐term care service, educational level, marital status, and income (monthly).
3.2.2. Practice Environment Survey Scale
The 40‐item “Practice Environment Survey Scale” (Lee et al. 2008) was used to assess the participants' feelings about the practice environment. The questionnaires were divided into versions for nurses and NAs. The questions covered eight aspects: safety (five items), supply (five items), resources (five items), salary and benefits (five items), continuing education (five items), support (five items), equipment (five items), and respect (five items). The Likert 5‐point scale was used for scoring, ranging from very dissatisfied (1 point) to very satisfied (5 points). Higher scores indicated higher satisfaction with the practice environment. In this study, the Cronbach's α for this instrument was 0.90.
3.2.3. Work Design Questionnaire
The 24‐item Work Design Questionnaire was used to measure the job characteristics of the participants (Chiou et al. 2010). The scale has five dimensions: job autonomy (nine items), job variety (four items), job significance (four items), job identity (four items), and job feedback (three items). The Likert 5‐point scale was used for scoring, ranging from strongly disagree (1 point) to strongly agree (5 points). The higher the score, the greater the agreement with the job characteristics of the item In this study, the Cronbach's α for this tool was 0.97.
3.2.4. Powerlessness Scale
This study first established a 28‐item powerlessness scale through literature verification (e.g., Lim et al. 2020; Tebbeb et al. 2022; Vachon and Guité‐Verret 2020) and expert content review. After an exploratory factor analysis (EFA), two questions were deleted because they had similar loadings on the two factors. Finally, three factors were confirmed for the 26 questions: work meaning (8 questions), work control (10 questions), and work alienation (8 questions). The Kaiser–Meyer–Olkin (KMO) value was 0.98, and Bartlett's sphericity test was significant (χ 2 = 11 716.17, p < 0.001), indicating the adequacy of the scale for factor analysis (Widaman and Helm 2023). These three factors explained 28.63%, 26.39%, and 25.48% of the variance, respectively, with an overall explained variance of 80.50%. The Cronbach's α values of each factor ranged from 0.96 to 0.97, and the Cronbach's α value of the entire scale was 0.98. The Likert 5‐point scale was used, ranging from strongly disagree (1 point) to strongly agree (5 points), with higher scores indicating a higher degree of powerlessness.
3.3. Ethical Considerations
This study was approved by the Human Research Ethics Review Committee of Chung Shan Medical University Hospital (number: CS2‐23011), and the purpose of the study was explained in writing after obtaining consent from each institution. After obtaining written consent from the participants, a paper‐based questionnaire survey was conducted, and participants were asked to complete the questionnaire anonymously. All questionnaires were collected by researchers, and the institution manager was blinded to who completed the questionnaire. All questionnaires were coded and archived. This study was conducted between April 2023 and March 2024.
3.4. Data Analysis
SPSS version 25.0 was used for the data analysis. The independent variables were demographics, practice environments, and work characteristics, and the dependent (outcome) variable was powerlessness. For scales and subscales with different numbers of questions or non‐percentile mean scores, a standardized mean score was calculated from 0 to 100 ([mean/number of questions/highest score per question] × 100) to enable comparison. All variables do not have missing data. Furthermore, each data point that needed to be grouped was examined for normal distribution. All objects in this study have skewness values between −0.95 and 1.68 and kurtosis values between −1.424 and 2.29. According to Kim's (2013) suggestion of an absolute skewness value less than 2 or an absolute kurtosis lower than 7, these may be used as reference values for determining substantial normality. In the current study, as a result of the assumption of normality being met, an independent sample t‐test and Pearson's correlation were used to test Hypotheses 1, 2, 3. Hierarchical regression and stepwise regression analyses were used to test Hypotheses 4 and 5. If the demographic characteristics were significantly related to the outcome and categorical variables, they were included in the regression model as dummy variables. The variance inflation factor (VIF) and tolerance values were also calculated during the regression analysis to evaluate the multicollinearity among the independent variables. The findings (Tables 4 and 5) demonstrated that the multicollinearity was within the allowable limits, since all tolerance values were greater than 0.1 and the VIF values were less than 10 (Shrestha 2020; Sulaiman et al. 2021).
TABLE 4.
Predictors of powerlessness by hierarchical regression analysis (N = 338).
| Variables | Nurses (n = 156) | |||||||
|---|---|---|---|---|---|---|---|---|
| Model 1 | Model 2 | Model 3 | Collinearity statistics | |||||
| β | t | β | t | β | t | Tolerance | VIF | |
| Salary (monthly) | −0.197 | −2.491* | −0.132 | −2.089* | −0.116 | −1.881 | 0.983 | 1.018 |
| Practice environment | −0.602 | −9.542** | −0.381 | −3.857** | 0.393 | 2.546 | ||
| Job characteristics | −0.285 | −2.874* | 0.389 | 2.573 | ||||
| F | 6.207* | 50.445*** | 37.979*** | |||||
| R 2 | 0.039 | 0.397 | 0.428 | |||||
| Adjusted R 2 | 0.033 | 0.389 | 0.417 | |||||
| Variables | Nurse aides (n = 182) | |||||||
|---|---|---|---|---|---|---|---|---|
| Model 1 | Model 2 | Model 3 | Collinearity statistics | |||||
| β | t | β | t | β | t | Tolerance | VIF | |
| Years of work experience | −0.203 | −2.781* | −0.011 | −0.185 | −0.014 | −0.237 | 0.905 | 1.104 |
| Practice environment | −0.654 | −11.112*** | −0.695 | −7.462*** | 0.367 | 2.724 | ||
| Job characteristics | 0.052 | 0.559 | 0.368 | 2.715 | ||||
| F | 7.733* | 68.237*** | 45.421*** | |||||
| R 2 | 0.041 | 0.433 | 0.434 | |||||
| Adjusted R 2 | 0.036 | 0.426 | 0.424 | |||||
Abbreviations: β, standardized regression coefficient; VIF, variance inflation factor.
p < 0.05.
p < 0.01.
p < 0.001.
TABLE 5.
The subscales of practice environment or job characteristics in predicting powerlessness by stepwise regression analysis (N = 338).
| Variables | Nurses (n = 156) | |||||
|---|---|---|---|---|---|---|
| Model 1 | Model 2 | Collinearity statistics | ||||
| β | t | β | t | Tolerance | VIF | |
| Autonomy | −0.616 | −9.698*** | −0.391 | −4.982*** | 0.565 | 1.769 |
| Salary and benefits | −0.348 | −4.431*** | 0.565 | 1.769 | ||
| F | 94.06 | 62.53 | ||||
| R 2 | 0.379 | 0.450 | ||||
| Adjusted R 2 | 0.375 | 0.443 | ||||
| Variables | Nurse aides (n = 182) | |||||||
|---|---|---|---|---|---|---|---|---|
| Model 1 | Model 2 | Model 3 | Collinearity statistics | |||||
| β | t | β | t | β | t | Tolerance | VIF | |
| Respect | −0.643 | −11.275*** | −0.463 | −5.398*** | −0.253 | −2.018* | 0.199 | 5.015 |
| Equipment | −0.238 | −2.770** | −0.280 | −2.252* | 0.388 | 2.580 | ||
| Continuing education | −0.184 | −2.058* | 0.196 | 5.097 | ||||
| F | 127.134*** | 69.760*** | 48.662*** | |||||
| R 2 | 0.414 | 0.438 | 0.451 | |||||
| Adjusted R 2 | 0.411 | 0.432 | 0.441 | |||||
Abbreviations: β, standardized regression coefficient; VIF, variance inflation factor.
p < 0.05.
p < 0.01.
p < 0.001.
4. Results
4.1. Participants
As shown in Table 1, the majority of nurses were female (96.8%); 65.4% were married; the average age was 40.49 (SD = 11.05) years; the average years of work experience was 15.39 (SD = 9.83) years; and the average years of work experience in long‐term care was 7.75 (SD = 5.76) years. Most nurses had a college or university degree (92.9%). NAs were also mainly female (73.1%), 70.3% were married, the average age was 49.62 (SD = 13.53) years, the average working experience was 16.95 (SD = 13.03) years, and the average long‐term care working experience was 8.17 (SD = 5.77) years. Most had a high school or vocational college degree or lower (57.7%). Most nurses and NAs have salary incomes below NT$40 000, accounting for 65.4% and 96.2%, respectively.
TABLE 1.
Analysis of powerlessness among nurses and nurse aides with different demographic characteristics (N = 338).
| Variables | Nurses (n = 156) | Nurse aides (n = 182) | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Powerlessness | Powerlessness | |||||||||||
| M (n) | SD (%) | M | SD | r/t | p | M (n) | SD (%) | M | SD | r/t | p | |
| Age | 40.49 | 11.05 | −0.023 | 0.772 | 49.62 | 13.53 | −0.125 | 0.092 | ||||
| Years of work experience | 15.39 | 9.83 | −0.143 | 0.074 | 16.95 | 13.03 | −0.203 | 0.006* | ||||
| Years of long‐term care service | 7.75 | 5.76 | 0.054 | 0.502 | 8.17 | 5.77 | −0.139 | 0.061 | ||||
| Gender | −0.864 | 0.389 | −0.848 | 0.398 | ||||||||
| Male | 5 | 3.2 | 47.00 | 33.94 | 49 | 26.9 | 46.16 | 18.55 | ||||
| Female | 151 | 96.8 | 55.09 | 20.12 | 133 | 73.1 | 48.92 | 19.83 | ||||
| Education level | 1.540 | 0.126 | 1.055 | 0.293 | ||||||||
| ≤ High school | 11 | 7.1 | 64.00 | 24.66 | 105 | 57.7 | 49.49 | 19.42 | ||||
| ≥ College/university | 145 | 92.9 | 54.13 | 20.17 | 77 | 42.3 | 46.40 | 19.55 | ||||
| Marital status | −0.038 | 0.970 | 1.430 | 0.154 | ||||||||
| Single | 54 | 34.6 | 54.74 | 19.93 | 54 | 29.7 | 51.35 | 18.08 | ||||
| Married | 102 | 65.4 | 54.87 | 21.01 | 128 | 70.3 | 46.84 | 19.96 | ||||
| Salary (monthly) | 2.491 | 0.014* | −0.014 | 0.989 | ||||||||
| NT$40 000 | 102 | 65.4 | 57.76 | 21.16 | 175 | 96.2 | 48.12 | 19.23 | ||||
| ≥ NT$40 000 | 54 | 34.6 | 49.28 | 18.36 | 7 | 3.8 | 48.29 | 26.87 | ||||
Note: Mean (M), standard deviation (SD), Pearson product–moment correlation coefficient (r), independent samples t‐test statistic (Student's t‐test).
p < 0.05.
4.2. Powerlessness Scores Based on Different Demographic Characteristics
Most demographic characteristics of nurses and NAs showed no significant differences in powerlessness. Among nurses, only those with a salary income below 40 000 had a higher sense of powerlessness than those with a salary income above 40 000 (t = 2.491, p = 0.014). For NAs, years of work experience showed a significant negative correlation with a sense of powerlessness (r = −0.203, p = 0.006). Although female nurses and NAs (mean = 55.09 and 47.00, respectively) had higher powerlessness scores than male nurses and NAs (mean = 48.92 and 46.16, respectively), the difference was not significant. Similarly, nurses and NAs with a high school/vocational college education or below (mean = 64 and 54.13, respectively) had higher powerlessness scores than those with a college/university education or above (mean = 49.49 and 46.40, respectively); however, the difference was not significant. There was no significant correlation between nurses' marital status and powerlessness. Although unmarried NAs (including single divorced ones) (mean = 51.35) had higher powerlessness scores than married NAs (mean = 46.84), the difference was not significant. Age and years of long‐term care did not correlate with powerlessness (Table 1).
4.3. Comparison of Nurses' and NAs' Powerlessness, Practice Environment, and Job Characteristics
Table 2 shows that nurses (mean = 42.18) and NAs (mean = 37.07) have a low to medium level of powerlessness, but nurses have a significantly higher sense of powerlessness than NAs (t = 3.046, p = 0.003). In three subscales (work meaning, work control, and work alienation), nurses also have significantly higher scores than NAs. Therefore, Hypothesis 1 is valid. In terms of the practice environment, both nurses (mean = 79.49) and NAs (mean = 83.19) scored in the medium to high range, and NAs scored significantly higher than nurses (t = −2.60, p = 0.009). In the eight domains of the practice environment, except for social support, NAs also scored significantly higher than nurses. Therefore, Hypothesis 2 is valid. Nurses and NAs also had medium to high levels of job characteristics, with average values of 77.78 and 77.77, respectively. There is no significant difference between the two; therefore, Hypothesis 3 is not valid.
TABLE 2.
Comparison of powerlessness, practice environment, and job characteristics between nurses and nurse aides (N = 338).
| Variables | Nurses (n = 156) | Nurse aides (n = 182) | t | p | ||||
|---|---|---|---|---|---|---|---|---|
| M | SD | M a | M | SD | M a | |||
| Powerlessness | 54.83 | 20.58 | 42.18 | 48.18 | 19.48 | 37.07 | 3.046 | 0.003* |
| Meaningfulness | 16.57 | 6.70 | 41.13 | 14.35 | 5.96 | 35.88 | 3.229 | 0.001* |
| Alienation | 16.10 | 6.30 | 40.25 | 14.18 | 5.88 | 35.45 | 2.894 | 0.004* |
| Control | 22.16 | 8.43 | 44.32 | 19.66 | 8.47 | 39.32 | 2.711 | 0.007* |
| Practice environment | 158.97 | 26.495 | 79.49 | 166.37 | 25.524 | 83.19 | −2.60 | 0.009* |
| Safety | 20.04 | 3.693 | 80.16 | 21.01 | 3.193 | 84.04 | −2.58 | 0.010* |
| Pay | 19.56 | 3.856 | 78.24 | 20.41 | 3.620 | 81.64 | −2.09 | 0.037* |
| Respect | 19.99 | 3.561 | 79.96 | 20.91 | 3.415 | 83.64 | −2.40 | 0.017* |
| Support | 20.71 | 3.257 | 82.84 | 21.12 | 3.338 | 84.48 | −1.15 | 0.249 |
| Continuing education | 19.83 | 3.681 | 79.32 | 20.77 | 3.400 | 83.08 | −2.44 | 0.015* |
| Resources | 19.58 | 3.810 | 78.32 | 20.52 | 3.606 | 82.08 | −2.32 | 0.021* |
| Supplies | 19.87 | 3.689 | 79.48 | 20.96 | 3.586 | 83.84 | −2.73 | 0.007* |
| Equipment | 19.40 | 4.122 | 77.60 | 20.68 | 3.745 | 82.72 | −2.98 | 0.003* |
| Job characteristic | 93.33 | 14.442 | 77.78 | 93.32 | 16.60 | 77.77 | 0.002 | 0.999 |
| Autonomy | 35.02 | 5.164 | 77.82 | 34.72 | 5.726 | 77.16 | 0.501 | 0.616 |
| Variety | 16.00 | 2.907 | 80.00 | 15.42 | 3.434 | 77.10 | 1.673 | 0.095 |
| Significance | 15.21 | 3.127 | 76.05 | 15.44 | 3.300 | 77.20 | −0.649 | 0.517 |
| Identity | 15.59 | 3.005 | 77.95 | 15.84 | 3.248 | 79.20 | −0.717 | 0.474 |
| Feedback | 11.51 | 2.422 | 76.73 | 11.91 | 2.444 | 79.40 | −1.507 | 0.133 |
Note: Mean (M), standard deviation (SD), independent samples t‐test statistic (Student's t‐test).
Adjusted mean = [mean/of number of questions/highest score per question] × 100.
p < 0.05.
4.4. Correlation Between Powerlessness, Work Environment, and Job Characteristics
As shown in Table 3, powerlessness among nurses was significantly negatively correlated with practice environment and job characteristics (r = −0.60, p < 0.01; r = −0.62, p < 0.01), while practice environment was significantly positively correlated with job characteristics (r = 0.78, p < 0.01). Similarly, powerlessness among NAs was significantly negatively correlated with the working environment and job characteristics (r = −0.66, p < 0.01; r = −0.50, p < 0.05), while the practice environment was significantly positively correlated with job characteristics (r = 0.79, p < 0.01).
TABLE 3.
The relationship between the working environment, job characteristics and powerlessness of nurses and nurse aides (N = 338).
| Variables | Nurses (N = 156) | Nurse aides (n = 182) | ||
|---|---|---|---|---|
| 1 | 2 | 1 | 2 | |
|
||||
|
−0.60** | −0.66** | ||
|
−0.62** | 0.78** | −0.50** | 0.79** |
p < 0.01.
4.5. Predictors of Powerlessness
In the first stage, hierarchical regression analysis was performed, and the “income” factor, which showed a significant negative correlation between the nurses' demographic characteristics and powerlessness, was included. Model 1 showed that “income” had a significant explanatory power (β = −0.197, p = 0.014). Model 2 added “practice environment,” and the results showed that the nurses' “income” variable was still significant (β = −0.132, p = 0.038), and the “practice environment” was also significant (β = −0.602, p < 0.001). The adjusted R 2 value had an explanatory power of 38.9%. Model 3 included “job characteristics” in the analysis, and the results showed that the “practice environment” was still significant (β = −0.381, p < 0.01), and the “work characteristics” were also significant (β = −0.285, p = 0.005). These results indicating lower satisfaction with the practice environment and agreement with work characteristics were significantly associated with greater powerlessness. However, “income” was no longer significant (β = −0.116, p = 0.062), and the overall model had an explanatory power of 41.7% after adjustment. Therefore, Hypothesis 4 is valid (Table 4).
In the analysis of NAs, Model 1 showed that “years of experience” was significant (β = −0.203, p = 0.006), and Model 2 showed significance after adding “practice environment” (β = −0.654, p < 0.001), but “years of experience” became insignificant (β = −0.011, p > 0.05). Model 3 added “job characteristics” but it did not reach significance, while “practice environment” remained significant (β = −0.695, p < 0.001), indicating that having a lower satisfaction with the practice environment was significantly related to greater powerlessness. After the overall model was adjusted, the R 2 was 42.4%, which was similar to the explanatory power of nurses. However, job characteristics did not have explanatory power; therefore, Hypothesis 5 is partially valid.
In the first stage of the hierarchical regression analysis, we found that the practice environment and job characteristics were important factors associated with powerlessness among nurses. To find out more specifically which domain (subscale) is the main factor, we further performed a stepwise regression analysis on the explanatory power of the eight domains of the practice environment and the five domains of job characteristics on powerlessness. As shown in Table 5, “job autonomy” and “salary and benefits” (β = −0.391, t = 4.982; β = −0.348, t = −4.431) are significant, with an overall explanatory power of 44.3%. In other words, nurses who perceive lower “job autonomy” and “salary and benefits” have greater powerlessness. In addition, the work environment was the main factor associated with powerlessness among NAs. Stepwise regression analysis showed that, among the eight subscales, mutual respect (β = −0.253, t = −2.018), complete equipment (β = −0.280, t = −2.252), and continuing education (β = −0.184, t = −2.058) are important dimensions associated with powerlessness among NAs, with a total explained variance of 44.1%. These results indicate that NAs who perceived less mutual respect, complete equipment, and continuing education have greater powerlessness.
5. Discussion
This study found that practicing nurses and NAs in residential long‐term care institutions had medium to low levels of powerlessness; however, nurses felt more powerless than NAs. This outcome is similar to the results of previous studies (Beaulieu et al. 2023; Mohammadi et al. 2021; Swoboda et al. 2020) that pointed out that hospital nurses encountered many obstacles to care owing to rapid and continual changes in the workplace, which made them feel exhausted, stressed, and powerless. These feelings may also be related to the fact that nurses hold more positions and responsibilities than NAs do, while nurses in long‐term care institutions often need to spend more energy guiding NAs and therefore bear heavier responsibilities.
From the perspective of the three subscales of powerlessness (meaningfulness, alienation, and control), both nurses and NAs scored the highest in the “control” subscale, indicating that they felt powerless because they had lost control of the care situation. This may be related to the inequality between nurses and doctors in the eyes of patients and their families. In Taiwan, doctors have the advantage of being professionals, and the social class of patients also reflects the class differences in the medical sector. For example, caring for older adults or patients with dementia has become the least prestigious type of nursing work in the medical care system. Therefore, the intrinsic value of nurses' job identification is far lower than that of doctors (Chang 2022; Lee 2023). Furthermore, this result echoes the conclusion of George et al.'s (2023) qualitative study that nurses believe patient care is beyond their control. George et al.'s (2023) research participants were hospital clinical nurses, and this shows that nurses and NAs in long‐term care institutions face dilemmas that are similar to those faced by hospital clinical nurses.
Notably, nurses scored their current practice environments at medium to high levels (mean = 158.97). This score was higher than that of 706 clinical nursing practice environments surveyed by Lee et al. (2008) (mean = 129.21), indicating that the effectiveness of nursing advocates in promoting high‐quality practice environments has increased in recent years. In addition, this study showed that the practice environment score of NAs (mean = 166.67) was significantly higher than that of nurses, which echoed the results of Hung et al.'s (2015) study in which NAs were more satisfied with their practice environment than nurses were but their participants were mainly hospital nurses and NAs. We found no significant difference in job characteristics between the two, indicating that in long‐term care institutions, the job characteristics of nurses and NAs are more closely aligned; in other words, their perceptions of job autonomy, variety, significance, identity, and task feedback are similar.
The results of the two‐step regression analysis showed that the job characteristics of “job autonomy” and the practice environment of “salary and benefits” were significant for nurses' feelings of powerlessness. Job autonomy was the first item selected, indicating its importance in nurses' practice environments. This result is similar to the argument of Chun and Cho (2018) that the lower the job autonomy of nurses, the lower their job satisfaction. Our findings also echo the suggestion by Othman and Nasurdin (2019) that the higher the job autonomy nurses have, the more engaged they are in their work. In addition, in our current study, 65.4% of the nurses had a salary below NT$40 000. It also shows that investment in long‐term care funds ignores the remuneration of the basic staff in long‐term clinical environments.
In the first step of the hierarchical regression analysis for NAs, we discovered that only the working environment had explanatory power for their sense of powerlessness. In the stepwise regression analysis of the impact of the eight aspects of the working environment on the sense of powerlessness, we found that “mutual respect,” “complete equipment,” and “continuing education” were associated with powerlessness among NAs. Mutual respect particularly occupies an important position in the sense of powerlessness among NAs. In addition, in terms of “complete equipment” and “continuing education,” long‐term care work tasks often involve activities and moving cases; therefore, complete equipment is equally important. In addition, because medical care is constantly being updated, NAs need continuing education.
5.1. Limitations
This study adopted convenience sampling to select nurses and NAs from 24 residential long‐term care institutions in Central Taiwan. Its inferences on the correlation between the working environment, job characteristics, and powerlessness of nurses and NAs in long‐term care institutions are inevitably limited due to the regional focus. In addition, we did not find an assessment tool suitable for the practice environment of long‐term care institutions; consequently, we used the practice environment survey scale developed by the ICN (2007, 2014). Some items may not have been included because of changes in the current practice environment. Thus, we recommend that future studies should be conducted in other regions to strengthen our findings, and the selection of practice environment survey scales should be diversified to include new items related to the current practice environment of long‐term care institutions, such as the use of high‐tech information monitoring equipment.
6. Conclusion
Long‐term care is currently the focus of global attention. Many countries are facing the challenge of human resources in long‐term care institutions. Stabilizing human resources and improving the quality of care in such institutions are common goals. Our study reflects the perspectives of nurses and NAs who work under challenging long‐term care conditions in Taiwan's long‐term care institutions. The findings can provide a reference for managers or policy makers of long‐term care institutions to plan and improve the practice environments and work designs.
This study found that practice environment and job characteristics are significant predictors of nurses' feelings of powerlessness in residential long‐term care institutions. Essentially, the higher the nurses' satisfaction with the practice environment and the stronger the job characteristics of variety, autonomy, identity, significance, and feedback are, the lower their feelings of powerlessness. Finally, the influence of important domains was reconfirmed, showing that “job autonomy” in job characteristics and “salary and benefits” in the practice environment are significant predictive domains of nurses' feelings of powerlessness. This result reflects that nurses in long‐term care facilities face the same issues as hospital nurses: the lack of job autonomy and unsatisfactory salary and benefits.
In addition, the sense of powerlessness among NAs was most strongly influenced by their satisfaction with the practice environment. The influence of important domains was reconfirmed, showing that the important predictive domains associated with NAs' sense of powerlessness were “mutual respect,” “complete equipment,” and “continuing education” in the practice environment. The findings indicate that the tasks and corresponding demands of NAs and nurses are different.
Author Contributions
Hsiang‐Chu Pai and Rong‐Fang Shih were responsible for the study conception and design. Rong‐Fang Shih performed the data collection. Hsiang‐Chu Pai was involved in data analysis, manuscript drafting, and critical revisions for important intellectual content.
Ethics Statement
The Institutional Review Board (IRB) of Chung‐Shan Medical University Hospital granted the study's permission and design (CSMUH No: CS2‐23011; date: April 3, 2023).
Conflicts of Interest
The authors declare no conflicts of interest.
Shih, R.‐F. , and Pai H.‐C.. 2025. “The Effects of Practice Environment and Job Characteristics on Nurses and Nurse Aides' Feelings of Powerlessness in Residential Long‐Term Care Institutions.” Nursing & Health Sciences 27, no. 3: e70210. 10.1111/nhs.70210.
Funding: The authors received no specific funding for this work.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.