1.

Introduction

Power is a widely used concept in both the physical and social sciences, and as a result, there are many definitions. In the physical sciences power refers to the amount of energy transferred per unit of time. Electricians work to provide and restore this type of power as a matter of course. Mathematicians have a different notion of power in mind when they talk about a numeral to the second (or third) power. Sociologists describe power as the ability to impose ones will upon others, and savvy researchers conduct power analyses before they begin their experiments. Several definitions of power have been used in nursing. Power has been defined as having control, influence, or domination over something or someone (Chandler, 1992). Another definition views power as "the ability to get things done, to mobilize resources, to get and use whatever it is that a person needs for the goals he or she is attempting to meet" (Kanter, 1993 p.166) For Benner (2001), power includes caring practices by nurses which are used to empower patients. Power may also be viewed as a positive, infinite force that helps to establish the possibility that people can free themselves from oppression (Ryles, 1999). Some researchers have described types of power, such as legal, coercive, remunerative, normative, and expert power (Conger & Kanungo, 1988). Of particular interest to nursing is the concept of expert power, which has been defined as "the ability to influence others through the possession of knowledge or skills that are useful to others" (Kunsch, 1996, p.198). Benner (2001) has

described qualities of power associated with caring provided by nurses such as transformative and healing power. Transformative and healing power contribute to the power of caring, which is central to the profession of nursing Benner (2001). Power is necessary to be able to influence an individual or group. Nurses need power to be able to influence patients, physicians, and other health care professionals, as well as each other. Powerless nurses are ineffective nurses, and the consequences of nurses lack of power has only recently come to light (Page, 2004). Powerless nurses are less satisfied with their jobs (Manojlovich & Laschinger, 2002), and more susceptible to burnout and depersonalization (Leiter & Laschinger, 2006). Lack of nursing power may also contribute to poorer patient outcomes (Manojlovich & DeCicco, in review). Studies suggest that there are compelling reasons to promote power in nursing.

A historical review of nurses power over nursing practice should include social, cultural, and educational factors that influence nurses power over their practice. Social and cultural factors that influence nursing power have their roots in the view of nursing as womens work (Wuest, 1994). Initially, nursing was a domestic role women were expected to fulfill in the home (Wuest). In addition, a lot of nursing work is done in private, behind drawn curtains (Wolf, 1989). The persistent invisibility of a lot of nursing work decreases nursings social status and perceived value (Benner, 2001; Wolf), contributing to powerlessness. The fact that womens right to vote is less than 100 years old suggests oppression of women was common in the not too distant past, and may explain in part ongoing powerlessness. Although the feminist movement of the 1960s did much to bring women in other professions on an equal footing with men, nursings low status in the health care hierarchy remains. Educational factors contribute to this situation, and they are twofold. First, nursing has historically been taught in hospitals, perpetuating nursings low status in relation to physicians and other health care providers. This educational factor may still be contributing to nursings powerlessness. Second, the multiple entry levels into nursing practice further dissipate whatever influence nursing may be able to generate. Nursings ongoing debate over entry level issues may be contributing, inadvertently, to the lack of power that education should be mitigating. Nurses lack of power may be rooted in a societal reluctance in general to discuss power openly (Kanter, 1979). Nurses may be more reluctant than most to discuss power because 95% of all nurses are women and women have not been socialized to exert power (Rafael, 1996). Historically nurses have had difficulty acknowledging their own power (Rafael). This reluctance to acknowledge and subsequently use ones power as a nurse may in part explain many nurses inability to control their practice. According to Rafael (1996) power has been viewed as a outcome of masculinity and in direct opposition to caring, which is seen as the essence of nursing and traditionally aligned with femininity. Many nurses may be reluctant to access or use power because they view power as a masculine attribute that is inconsistent with their selfidentities as women. Therefore, a masculine view of power may be contributing to nurses continuing lack of power. Historically access to and the content of nursing education has not been fully under the control of nurses (Rafael, 1996). Other groups continue to exert control over nurses professional lives, as exemplified by the increasing use of unlicensed health care personnel and the medical

lobby opposing nurse practitioners as primary health care providers (Rafael). It is small wonder that nursing remains powerless relative to other professions. Despite empirical evidence of the positive outcomes of empowerment for nursing practice, a historical perspective is helpful in understanding why many nurses remain disempowered. As long as nurses view power as only having control or dominance, and as long as nursing does not control its own destiny, nurses will continue to struggle with issues of power and empowerment

2.0 2.1

Importance of empowerment In Education

There was great concern regarding the education system even though this plays an integral role in the process of empowerment. This concern originates from entry into nursing school as supported by the statement of one participant: "entrance examinations only measure the academic capabilities of volunteers but do not measure their compatibility to the nursing profession." Another concern is the curriculum content, it is highly theoretical that many nurse educators think the best nurses are the nurses who have more medical information. They give them an extensive range of disease-related, pharmacological and physiological information, but don't spend even ten minutes on the nursing care in a class of two hours." Role models also played a significant role in the weakness of nurses. It seems nurse educators doubt their own confidence, competency, and autonomy and were ineffective role models for students. An experienced nurse educator believed that "due to inexperience and freshness of most of the nurse educators, they lacked self confidence and could not educate a good new nursing generation." A philosophy of nursing education was considered absent and the question at large was "what are the guidelines for nursing education"? Therefore, "there is no relationship between nursing and clinical setting and the clinical setting is inappropriate for students' clinical placement" as one senior nurse director said. As a result of all these factors, nursing schools will continue to graduate disempowered nurses. Providing continuing education was judged critical for nurses to maintain competency in the clinical setting and to become life-long learners so they can develop confidence in "giving voice" to continually improve nursing practice and build a community of empowered professionals. However, low staffing and lack of staff development resources by 'the Ministry of

Health and Medical Education' only blocked the cycle of empowerment. People who are educated are more empowered to carry out their work, but the ministry of health doesn't support in-service education for nurses".

2.2

In Management

Empowerment is important at most levels of health care delivery. Just as staff nurses do, nurse educators who feel engaged, effective and valued experience empowerment that allows them to be effective in staff development and to make decisions quickly on the job. Johnson also found that empowered nurse educators demonstrated greater flexibility in adapting to ongoing change. Similar characteristics were found among staff nurses who expressed a feeling of empowerment in their work. Laschinger et al have conducted extensive research on the empowerment of nursing staff and on leaderships ability to instill empowerment. Of particular interest here is work by Laschinger et al that used Kanters organizational theory as a foundation for clarifying the ways in which empowerment is understood and maintained by nursing staff, as well as how it is used effectively by nursing leaders. Another study by Laschinger et al, conducted in an acute-care setting, demonstrated that effective leadership is a source of empowerment for staff. McDermott et al found that organizational commitment is important particularly when human and economic resources are limited and when a high quality of nursing care must be maintained. Excellence in nursing may be successfully cultivated by finding new ways to empower their staff. Safety in the hospital environment is of primary concern for leaders, health care providers, patients, and their families. Working conditions within the hospital setting are often influenced by environmental and human concerns. Faulkner and Laschinger found that empowerment within the context of structural and psychological parameters was a significant factor in the delivery of high-quality health care. Job satisfaction and reduced job stress can be two of the positive consequences of promoting nurse empowerment and can serve to reduce nurse burnout. Enhancing hospital nurses experience of empowerment may stem the growing shortage of experienced nurses. A workforce is more likely sustainable when staff nurses trust and respect their direct managers. Unhealthy work environments, where nurses are emotionally drained and feel overwhelmed are

more likely to be settings that risk patient safety. Nurses who feel empowered in their role express confidence, and successful management who can empower their staff serve an important role in creating a healthy and safe work environment.

2.3

In Nursing Practice

Empowerment is as much a process as an outcome of developing the skills and perceptions of clients. It is not only something that happens but a process that is facilitated. In interpersonal health counseling, the primary goal is not to change clients' behavior and seek their compliance with the presented message but rather to raise critical awareness through learning and support, to give clients tools for making changes on their own. The aim is personal empowerment, control and choice, which means that patients become aware of changes in their knowledge and understanding, decision-making skills, enhanced self-esteem/sense of personal control, and development of various social, health and life skills. The basic point of departure for empowerment is taking into consideration the interactive nature of the individual and the environment: people are not completely controlled by their environment nor can they fully control their physical, social or economic circumstances (Tones, 1994). Empowering health counseling is based on recognizing clients' competence, resources, explanations of action styles of coping and support networks. Client initiative, clients' realizations and clients' expressions of their opinions and interpretations are the basis on which clients can approach health issues in collaboration with professionals. They are of crucial importance for their decisions on future action. All this supports the notion that empowering health counseling is significant. Because learning about personal health is complex, the key issue of empowering health counseling is partnership and reciprocal conversation in a confidential relationship. This means that clients not only analyze their situation but also have an opportunity to plan what to do next, and how to go on and to construct their own solutions to health issues. In this type of hospital health counseling, either patients raise the issues (i.e. determine the topics) or the nurses do so in a sensitive and non-threatening manner. Nurses recognize and respect patients' experiences, knowledge and skills, and make their own professional knowledge and expertise available to them, which are important aspects of nursepatient. The emphasis is placed

on patient-driven health counseling, where patients' life situations are respected, patient-initiated actions are supported, and shared knowledge and deep understanding are nurtured. The nurse's institutional task is not only to facilitate patient participation but also to promote patients' awareness of their routines and preconceptions as they are revealed to both interlocutors. This should lead to the aim of interaction, which is to activate self-reflection and re-evaluation and reorganization of patients' activities. The assumption is that new knowledge is gained in this process as a result of empirical realization and deliberation (Feste and Anderson, 1995) which means that both patients and nurses have linked new knowledge to existing knowledge. Thus, patients learn to interpret and outline even familiar health problems in new ways that conform to their worldview. As for nurses, empowerment calls for not only sensitivity but also an ability to accurately perceive patients' messages.

3.0 3.1

Implications of Empowerment In Education

Nurses work on the front lines of the health care industry, tending to patients' daily needs and ensuring that they receive a high level of care. While nurses often work under the direction of physicians, it is important that these important health care workers also feel autonomous and in control of patient care. If nurses are not empowered, they will feel hesitant when making decisions and will second guess their choices, a practice that could prove costly. Creating an environment of empowerment is easy to do if you promote and celebrate decision-making among your nurses.

3.2

In Management

Throughout the world, nurse leaders have the opportunity to make a difference with respect to health systems reforms. Effective leadership depends on effective leadership development. Theoretical empowerment framework empowered participants who successfully completed leadership projects and empowered others in their practice environments through strategies such as information sharing and participatory decision-making. The use of a theoretical empowerment framework that is related to an extensive body of nursing research will provide

numerous opportunities for further research related to nursing leadership development and nurse/nurse leader outcomes. Therefore it has important implications with respect to nursing practice, policy and research. Empowerment also has implications for the relationship between nurse and patient. Nurses wishing to empower clients must understand the complexity of this approach because failure to do so could result in the nurse not recognizing the need for an individual approach which takes into account patients' differing circumstances. This could result in patients being overloaded with information, creating unnecessary anxiety, rather than the nurse using his/her skills to assess and address individual needs.

3.3

In Nursing Practice

When the patient discusses the reason for her admission to the hospital, the nurse builds up a positive, healthier vision of the future through other patients' experiences. She makes her professional knowledge and expertise available to the patient. This lends a touch of reality and possibly builds on the patient's strengths in this situation. The nurse attempts to dispel the patient's concerns about the risks of the operation. Her tone is convincing, and her non-verbal messages also inspire confidence: she looks at the patient, reinforces her message by nodding her head and gestures with her hands. Encouraged by the nurse, the patient can have a vision of her postoperative future.

4.0

Conclusion

Currently, nurses have demonstrated a strong commitment to change and improvement in the health care services. Nursing has been progressive as evidenced by comparing the history of nursing to where they are now. Therefore, empowerment is essential for enhancing nurses' role, strengthening the professional image, and continuously improving the healthcare system nationally and globally. Restructuring nursing services will eliminate barriers to poor quality nursing care, inadequate educational preparation, role ambiguity and low self-esteem among nurses. The nurses' experiences and their perceptions regarding empowerment were studied and a model was developed for empowerment of the nursing profession.

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