Key words: burnout, empowerment, feminist theory, job satisfaction, nursing outcomes, nursing practice, nursing practice environment, power, relational theory, socialist feminism
The new millennium is upon us. Many advances in technology and health care indeed make this a brave new world. However, relatively little has changed in nursing, where almost 95% of all nurses are still women (Spratley, Johnson, Sochalski, Fritz, & Spencer, 2000). Even now, years after the feminist movement, many nurses do not feel empowered, and what we do "as nurses does not seem to be working" (Fletcher, 2006, p. 50). An examination of the state of the science on power and empowerment in nursing is warranted, to determine if the literature can provide insights into how, if at all, nursing can garner power for the profession as well as for patient care.
This paper will begin with an examination of the concept of power; move on to a historical review of nurses’ power over nursing practice; describe the kinds of power over nursing care needed for nurses to make their optimum contribution; and conclude with a discussion on the current state of nursing empowerment related to nursing care.
The Concept of Power
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 one’s will upon others, and savvy researchers conduct power analyses before they begin their experiments [http://en.wikipedia.org/wiki/Power].
...there are compelling reasons to promote power in nursing...Nurses need power to be able to influence patients, physicians, and other health care professionals.
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, power includes caring practices by nurses which are used to empower patients (Benner, 2001). 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" (Kubsch, 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 such as these suggest that there are compelling reasons to promote power in nursing.
Historical Review of Nurses’ Power over Nursing Practice
Although the feminist movement of the 1960s did much to bring women in other professions on an equal footing with men, nursing's low status in the health care hierarchy remains.
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 women’s 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 nursing’s social status and perceived value (Benner, 2001; Wolf), contributing to powerlessness.
The fact that women’s 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, nursing’s 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 nursing’s low status in relation to physicians and other health care providers. Since twenty-two percent of nurses in America today are diploma graduates (Spratley et al., 2000), this educational factor may still be contributing to nursing’s powerlessness. Second, the multiple entry levels into nursing practice further dissipate whatever influence nursing may be able to generate. Nursing’s ongoing debate over entry level issues may be contributing, inadvertently, to the lack of power that education should be mitigating.
Nursing's ongoing debate over entry level issues may be contributing, inadvertently, to the lack of power that education should be mitigating.
It has been over twenty years since both Styles and Hall maintained that power is central to nursing’s development as a profession (Hall, 1982; Styles, 1982). 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 (Spratley et al., 2000), 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 one’s 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 self-identities as women. Therefore, a masculine view of power may be contributing to nurses’ continuing lack of power.
Kanter (1993) maintains that power is acquired through the process of empowerment. She views empowerment as arising from social structures in the workplace that enable employees to be satisfied and more effective on the job (Kanter, 1993). Chandler argues that empowerment arises from relationships and not merely from the parceling out control, authority, and influence (Chandler, 1992). Empowerment has been conceptualized from many different perspectives (Kuokkanen & Katajisto, 2003). Empowerment may be either an individual or a group attribute (Ryles, 1999). It may arise from the work environment (Kanter, 1993) or from within one’s own psyche (Conger & Kanungo, 1988) and may be viewed as either a process or an outcome (Gibson, 1991).
The concept of empowerment emerged in the late 1960s and early 1970s as a result of the self-help and political awareness movements (Ryles, 1999). Although power has been discussed in nursing literature since the 1970s (Kalisch, 1978), Chandler (1986) was among the first to describe the process of empowerment in nursing. Chandler (1992) also distinguished between power and empowerment, noting that empowerment enables one to act, whereas power connotes having control, influence, or domination.
Ongoing research on empowerment in nursing has demonstrated that empowered nurses are "highly motivated and are able to motivate and empower others by sharing the sources of power" (Laschinger & Havens, 1996, p. 28). Empowered nurses experience less burnout (Laschinger, Finegan, Shamian, & Wilk, 2003) and less job strain (Laschinger, Finegan, & Shamian, 2001). Alternatively, disempowerment, or the inability to act, creates feelings of frustration and failure in staff nurses, even though they may still be accountable (Laschinger & Havens, 1996).
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.
Kinds of Power over Nursing Care Needed for Nurses to Make Their Optimum Contribution
There are at least three types of power that nurses need to be able to make their optimum contribution. The various types of power can all be categorized as stemming from nurses’ control in three domains: control over the content of practice, control over the context of practice, and control over competence. The continued lack of control over both the content and context of nursing work suggests that power remains an elusive attribute for many nurses (Manojlovich, 2005a). In this section, power will be discussed as it is manifested by nurses’ control over the content, context, and competence of nursing practice.
Control Over the Content of Nursing Practice
Power is an attribute that nurses must cultivate in order to practice more autonomously because it is through power that members of an occupation are able to raise their status, define their area of expertise, and achieve and maintain autonomy and influence (Hall, 1982). One of the characteristics of a profession is that professionals have power over the practice of their discipline which is often referred to as professional autonomy (Laschinger, Sabiston, & Kutszcher, 1997). Autonomy represents one kind of power nurses need, and has been defined as "the freedom to act on what one knows" (Kramer & Schmalenberg, 1993, p. 62). Therefore a key element of empowerment is nurses’ control over their practice (Page, 2004). The ability to act according to one’s knowledge and judgment is known as control over the content of nursing practice (Laschinger et al., 1997), and is often synonymous with autonomy. High levels of autonomy increased nurses’ identification with the profession in one study (Apker, Ford, & Fox, 2003), providing recent empirical support for this supposition.
Having control over the content of nursing practice may not be enough to provide power for nurses.
Of all decision makers in the hospital environment, only the bedside nurse, who is in closest proximity to the patient, can fully appreciate subtle patient cues and trends as they arise and act on them to properly care for that patient (Manojlovich, 2005a). To identify the appropriate course of action and effectively function, professionals must have understanding and control over the entire spectrum of activities associated with the job at hand (Manojlovich). However, it may be that nurses are frequently unable to use their professional preparation, which focuses on autonomous practice and independent decision making, because they are powerless relative to organizational administrators and medical staff (Manojlovich). Having control over the content of nursing practice may not be enough to provide power for nurses.
Control Over the Context of Nursing Practice
Besides control over the content of nursing practice, which represents one type of power, a related type of control is known as control over the context of practice, and represents another type of power that nurses need (Laschinger et al., 1997). Over twenty years ago it was noted that "nurses should be more meaningfully involved in the running of hospitals" (Prescott & Dennis, 1985, p. 348). Nurses’ involvement in hospital affairs is one of the hallmarks of a magnet hospital environment (McClure & Hinshaw, 2002) but otherwise may not be apparent.
Research on magnet hospital characteristics has largely demonstrated relationships between the work environment and patient outcomes (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Aiken, Sloane, Lake, Sochalski, & Weber, 1999). The positive findings of the magnet hospital research may be attributed to empowering organizational social structures, although they were not identified as such. Hospital characteristics which were found to attract and retain qualified staff nurses included decentralization and participatory decision making. Although relatively little attention has been paid to how a magnet work environment contributes to nurses’ sense of power (Upenieks, 2003c), repeated magnet hospital study findings of empowering workplace structures and their relationship to improved nursing and patient outcomes suggest that magnet hospitals attract nurses in part because of their empowering environments.
All of the magnet hospital studies have also consistently demonstrated positive benefits for nursing and patients when nurses control both the content and the context of their practice.
All of the magnet hospital studies have also consistently demonstrated positive benefits for nursing and patients when nurses control both the content and the context of their practice. In the original magnet hospital study, nursing staff felt able to influence decisions and were in control of their own practice, while recognizing the power of physicians and nurse leaders (McClure, Poulin, Sovie, & Wandelt, 1983). The original magnet hospital study also recognized that the power base of staff nurses emerged from nursing leadership, whose power came from staff, hospital administrators, and boards of trustees (McClure et al.). A more recent study has validated the magnet hospital findings, demonstrating that strong nursing leadership strengthens the effect of empowerment on nursing practice behaviors (Manojlovich, 2005c). Professional practice models, shared governance models, and collaborative governance all use similar processes to increase nurses’ participation in decision making, thereby increasing their control over the context of nursing practice and promoting power.
There is strong empirical justification for promoting nurses’ power through control over both the content and context of nursing practice. In multiple studies, patient outcomes were improved when the hospital organization was supportive of autonomous nursing practice (Aiken et al., 1999; Aiken, Clarke, & Sloane, 2000). In these studies, autonomous nursing practice was operationalized as control over the practice environment, decision-making ability, and collegial relationships with physicians, suggesting an important link between power and patient outcomes.
Control Over the Competence of Nursing Practice
A necessary precursor for both autonomy and power is competence (Kramer & Schmalenberg, 1993), which has its foundation in educational preparation. Power is maintained through knowledge development (Rafael, 1996), which is acquired through education and expertise. The multiple entry levels into nursing practice, as well as the low educational level of nurses (relative to other health care professionals) may contribute to nurses’ powerlessness. The statement, "Being less well-educated than other groups within the hospital puts nursing at a serious disadvantage in organizational politics" (Prescott & Dennis, 1985, p. 355), is no less true now than it was when written more than twenty years ago.
Nursing expertise is a related source of power that has a transformative effect on patients’ lives ((Rafael, 1996). Expertise is not the same as experience, nor can expertise be acquired on nursing units with high turnover (Benner, 2001). This suggests a complex relationship between organizational factors that contribute to nursing turnover and the development of nursing expertise. Educational preparation and expertise represent two additional types of power nurses need to make their optimal contribution to patient care.
Organizational systems aimed at promoting nurses’ power so that they can use their professional skills may provide an attractive and rewarding career choice for today’s sophisticated students (Bednash, 2000). There may be additional benefits for hospitals that promote nursing power. Bednash (2000) reported on a study indicating that hospitals that allowed their staff autonomy over their own practice and active participation in decision making about patient care issues were the most successful in recruiting and retaining nurses. In another study patient satisfaction improved when there was more organizational control by staff nurses (Aiken et al., 1999).
The Current State of Nursing Empowerment Related to Nursing Care
Part of the difficulty many nurses have in being powerful may be due to their inability to develop the types of power described in the previous section. Power over the content, context, and competence of nursing practice contributes to feelings of empowerment, but control in these three domains may not be enough. An examination of the two major areas of empowerment literature in nursing, as well as a third area not yet embraced by nursing, may help inform future directions for the development of power and empowerment for nurses.
Empowerment in nursing has largely been studied from two perspectives. Most nursing researchers view empowerment as either arising from the environment (Laschinger, Finegan, Shamian, & Wilk, 2001) or developing from one’s psychological state (Manojlovich, 2005b; Spreitzer, 1995).
Another contributor to nurses’ lack of power may be that they don’t understand how power can develop from relationships, as originally proposed by Chandler (1992). Therefore a third perspective on empowerment, not yet embraced by nursing, is gender specific. Relational theory explains how women engage in relationships to foster growth and nurturance (Fletcher, Jordan, & Miller, 2000). Women develop empathy and empowerment through relationships, although the mutual processes of empathy and empowerment are largely invisible (Fletcher et al., 2000).The answer to increasing nursing empowerment may lie in understanding workplace sources of power, expanding the view of empowerment to include the notion of empowerment as a motivational construct, and finally making more explicit growth fostering relationships which also contribute to power.
Theory of Structural Empowerment
The theory of structural empowerment states that opportunity and power in organizations are essential to empowerment, and must be available to all employees for maximal organizational effectiveness and success. The theory of structural empowerment was developed by Kanter (1993) who saw employees’ work behavior as arising from conditions and situations in the work place, and not from personal attributes (Laschinger & Havens, 1996).
There are four structural conditions identified by Kanter (1993) as being the key contributors to empowerment. They are: having opportunity for advancement or opportunity to be involved in activities beyond one’s job description; access to information about all facets of the organization; access to support for one’s job responsibilities and decision making; and access to resources as needed by the employee (Kanter, 1993). Empowerment is on a continuum, because the environment will provide relatively more or less empowerment, depending on how many of the four structures are present in the work setting. The theory of structural empowerment places the focus of causative factors of behavior fully on the organization, in effect maintaining that powerless individuals have not been exposed enough to the four empowering workplace structures.
In this worldview of empowerment, employees’ behavior is merely a response to the structural conditions they face in the work setting. Therefore, the qualities of a job and its context evoke behaviors from those in a job position that determine the likelihood of success (Kanter, 1993). Employees’ behavior becomes more effective, and organizational output increases and improves when the organization is structured to provide opportunity and power to all employees across all organizational levels (Kanter, 1993).
Laschinger and her colleagues have done the bulk of the work on structural empowerment in nursing (Laschinger, Finegan, Shamian, & Almost, 2001; Laschinger et al., 2003; Laschinger, Finegan, Shamian, & Wilk, 2004; Leiter & Laschinger, 2006; Sabiston & Laschinger, 1995). However evidence of the essence of structural empowerment, if not the name, appears in other research as well. Kramer and Schmalenberg (1993) identified organizational strategies necessary before individuals could act in an empowered manner. These included participative management, job enrichment, meaningful organizational goals, less bureaucracy, and involving staff in decision making (Kramer & Schmalenberg, 1993). Although not identified as conditions in the environment, the access to opportunity, resources and support that these strategies would provide would certainly strengthen nurses’ perceptions of empowerment.
Other than the magnet program there is additional support for configuring work environments in a way that promotes empowerment. Aiken and colleagues (2001) conducted an international study in five countries to compare nurse staffing, work environments, and patient outcomes. Even in countries with vastly different health care systems nurses reported similarities in workplace empowerment elements. The results of this international study further suggest that the relative presence or absence of specific environmental factors associated with structural empowerment may contribute to variation in nursing and patient outcomes in multiple countries.
There is evidence in the literature that structural empowerment contributes to higher levels of job satisfaction (Manojlovich, 2005d), and is interrelated with nursing leadership (Upenieks, 2003a). In fact, nursing leaders must empower themselves by first accessing empowering work environment structures before moving forward to offer these same empowering work conditions to their staff (Upenieks, 2003b).
Theory of Psychological Empowerment
Thus empowerment, as provided by the environment, tells part of the story, but alone it is not enough. Some environments are empowering because they allow workers to do what it is the workers feel is necessary to get the job done. In other words, these environments provide the sources of power. Other work environments may not be as empowering, yet there will still be a few hardy individuals who manage to do whatever it takes to be effective on the job. It may be that these people are able to recognize what few empowering social structures in the environment are present, and manipulate them, since it is only in recognition that the structures can be used.
An alternative theoretical perspective on empowerment acknowledges the fact that empowerment is also a psychological experience. Conger and Kanungo (1988) viewed empowerment as a motivational construct, while maintaining that it is still a personal attribute. They saw empowerment as enabling, which "implies motivating through enhancing personal efficacy" (Conger & Kanungo, 1988, p. 473). Spreitzer (1995) developed this version of empowerment further. According to Spreitzer, the process of psychological empowerment is a motivational construct which manifests as a set of four cognitions that are shaped by a work environment. The four cognitions are: meaning, competence, self-determination, and impact (Spreitzer, 1995).
Meaning occurs when there is congruence between a nurse’s beliefs, values, and behaviors, and job requirements (Laschinger, Finegan, & Shamian, 2001). Competence refers to confidence in one’s abilities to perform the job, and is also known as self-efficacy (Laschinger, Finegan, & Shamian). Self-determination, similar to autonomy, refers to feelings of control that are exerted over one’s work. Finally, impact is seen as a sense of being able to influence important organizational outcomes (Laschinger, Finegan, & Shamian).
Psychological empowerment is a process because it begins with the interaction of a work environment with one’s personality characteristics; then the interaction of environment with personality shapes the four empowerment cognitions, which in turn motivate individual behavior (Spreitzer, 1995). Psychological empowerment reflects an active rather than a passive orientation to work, and conveys the notion that individuals not only want to, but are able to, shape their work role and context (Boudrias, Gaudreau, & Laschinger, 2004).
Several studies have demonstrated the effect of psychological empowerment on nursing outcomes of burnout and nursing job satisfaction (Laschinger, Finegan, & Shamian, 2001; Laschinger, Finegan, & Shamian & Almost, 2001). Self-efficacy for nursing practice (one of the psychological empowerment cognitions) was recently found to contribute to professional nursing practice behaviors (Manojlovich, 2005b). In fact, this study demonstrated that structural empowerment contributed to professional practice behaviors through self efficacy, consistent with the notion that both forms of empowerment may be necessary to sustain professional practice behaviors (Manojlovich). Research has also shown that work environment characteristics, such as structural empowerment, contribute to psychological empowerment in both nursing (Laschinger, Finegan, & Shamian & Almost, 2001) and non-nursing populations (Spreitzer, 1996).
A Relational View of Empowerment
Relational theory may have greater relevance to the development of empowerment in nursing than either workplace or motivational views of empowerment because of the nature of nursing's work.
Despite the large amount of literature describing how to foster empowerment, a recent study done in New York reported that nurses are feeling they still lack power to influence their working conditions (Brewer, Zayas, Kahn, & Sienkiewicz, 2006). In addition to accessing workplace structures to garner structural empowerment, and developing power through psychological empowerment, yet one more perspective on empowerment may be required.
Viewing empowerment through a feminist lens may help explain persistent findings of disempowerment. Most feminist scholarship on nursing focuses on overcoming oppressive working conditions brought on by the patriarchal structure of medicine and the health care industry (Chinn, 1995; Sampselle, 1990). Feminist theory that focuses on eliminating oppression and seeking equal status for women is known as liberal feminism (Wuest, 1994). While this perspective has its merits, it tends to dichotomize the empowerment debate and becomes constraining when viewed as part of a dualistic ideology: masculinity/femininity; oppressor/oppressed; good/bad; right or wrong.
An alternative feminist perspective argues for a relational context to empowerment: one that values and rewards interactive relationships (Chandler, 1992; Rafael, 1996).
...a truly empowering environment for nurses should nurture reciprocal professional relationships.
Relational theory comes from the school of social feminism, and posits that women engage in growth fostering and nurturance relationships, which maintain society (Fletcher et al., 2000). Women foster growth and nurture others, deriving strength from the relationships and bonds that develop as a result of these activities (Fletcher et al.). By engaging in growth fostering relationships at work, mutual empowerment ensues and enables the achievement of others and increases one’s own job effectiveness (Fletcher et al.). Relational theory may have greater relevance to the development of empowerment in nursing than either workplace or motivational views of empowerment because of the nature of nursing work. As Chandler has argued:
Clinical knowledge and committee work is only one piece of the staff nurse-based formula for empowerment. The other critical variables are those underestimated, trivialized, and unexamined aspects of what has been women’s domain—the domain that nurses know and would prefer (Chandler, 1992, p.70).
Thus Chandler implies that a psychological belief in one’s ability to be empowered may not be enough to increase empowerment in nursing, but that a truly empowering environment for nurses should nurture reciprocal professional relationships.
Fletcher (2006) suggests a relational theory approach when she asserts that nurses need to focus on relationships to build power. Fletcher maintains that relationships are built through dialogue and self-awareness and that the development of self-awareness "can begin to break the cycle of oppression and lead to changes in the structures that oppress nurses" (Fletcher, 2006, p. 57). Benner (2001) also argues for power through relationships and caring: the core of nursing practice. When nursing embraces caring, empathy, and compassion as components of power, nurses will be more likely to adopt and accept power as part of their practice (Benner).
...there remains a need for research to examine the power that exists in relationships.
In conclusion, nurses’ power may arise from three components: a workplace that has the requisite structures that promote empowerment; a psychological belief in one’s ability to be empowered; and acknowledgement that there is power in the relationships and caring that nurses provide. Nursing research has been able to demonstrate the relationship between the first two components and empowerment; yet there remains a need for research to examine the power that exists in relationships. Nursing research from a relational theory perspective may help make nurses’ power more explicit and more visible, moving our understanding of power in nursing further than has previously been possible. A more thorough understanding of these three components may help nurses to become empowered and use their power for their practice and for better patient care.
Milisa Manojlovich PhD, RN, CCRN
Dr. Manojlovich graduated from an ADN program in 1985, and received CCRN certification in 1989. She maintains her CCRN status by practicing as a staff nurse in the Medical Intensive Care Unit at the University of Michigan Health System two days a month. She received her PhD in 2003, and is currently an Assistant Professor at the University of Michigan. Dr. Manojlovich has been fascinated by the hospital environment’s effect on nursing practice ever since becoming a nurse, and is developing a research program investigating how empowerment can improve both nursing and patient outcomes. Dr. Manojlovich has written numerous publications describing the relationship of empowerment to nursing variables and works closely with Dr. Heather Laschinger, one of the foremost experts on nursing empowerment.
Article published January 31, 2007
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