Abstract

In nursing, empowerment can enable nurses to raise concerns about patient safety and do so in a safe and supportive environment. Furthermore, empowering patients to gain more ownership of their health can positively influence both nurses and patients. This narrative review focused on the importance of empowering nursing students. The literature has determined that nursing students should feel valued and be treated equally and should work in an environment that is open and transparent to feel empowered. Fear of retaliation may prevent nursing students from speaking out about poor care and practices. Moreover, co-developing care and support regimens with service users benefited both nursing students and patients, as well as local communities, reduced stress and burnout, and allowed patients to self-care and act in their own best interests.

Introduction

The inception of the Ottawa Charter on Health Promotion (1) advocated that individuals and communities should be empowered to gain ownership and control over their health. Like other Western countries, the United Kingdom (UK) government has embraced the idea of more self-determination for patients within the National Health Service (NHS) and has embedded the principles of empowerment in several National Institute for Care and Health Excellence (NICE) guidelines, for example, the NICE for diabetes (2). Within the UK nursing profession, nurses, including nursing students, play a crucial role in promoting patient empowerment. This practice of involving patients in making decisions about their own healthcare can benefit both patients and the NHS in terms of reducing healthcare costs (3). This article outlines the importance of empowerment in the context of nursing students. This will draw on empowering nursing students through education to raise concerns and how they can do this in a safe environment. Moreover, this article will include the strengths-based nursing and healthcare leadership (SBNH-L) framework to enhance empowerment in healthcare settings. This will highlight the benefits of empowering patients through the lens of nursing students.

Information About Nursing Student Enrollment

At the beginning of the 19^th century, hospital treatment for medical conditions were not common in the UK, with the majority of care being undertaken within family units (4). The personal care of an individual was often performed by servants, who commanded little respect. This began to change in the 1860s with the introduction of Florence Nightingale’s and Mary Seacole’s philosophical caring ideas and the opening of the nightingale training school at St. Thomas’s Hospital in London (4). Since then, the nursing profession has gained status and professional autonomy, which requires professional registration with the nursing and midwifery council (NMC) (5). According to Traynor (4), along with the changes in the nursing profession, empowerment has also increased in importance for both nursing and nursing students as a key element to promoting practitioner-nurse relationships, increasing both patient and nurse autonomy, increasing compliance, and supporting patient-centered health care.

Defining Empowerment

Empowerment is difficult to define because of its complexity (6). However, authors such as Cayaban et al. (7) and Conger (8) stated that this concept is personal to each and every individual as it encompasses their energy and drive to do a good job and be successful. Given the challenges of defining empowerment, Ahn and Choi (9) noted that all organizations require the empowerment of their people to achieve their goals and mission statements. In nursing, this means enabling people’s ability to work efficiently and effectively in an environment where they can practice with autonomy, have the desire to be accountable for their actions, and be trusted with the responsibility to make evidence-based decisions in clinical practice (9). In the context of nursing students, empowerment is the act of strengthening nursing students’ confidence and belief in their sense of effectiveness (6) alongside their competence (10) with the ultimate effect of enabling them to feel motivated to provide optimum care for patients in the healthcare environment (11). Moreover, proponents such as Kanter (12) argued that organizational conditions must positively affect an individual’s internal motivation, and if this occurs, the individual will feel empowered. The organizational conditions described by Kanter (12) include access to resources, opportunities, information and support. Without these conditions, an individual would not achieve the desired organizational outcomes. Similarities can be observed in the nursing student context. They may not feel empowered to execute their role if the organization environment is not conducive to learning; therefore, they may feel deflated and lack enthusiasm. For example, nursing students require access to information about the people they care for and the policies of their organizations for which they work. Without this access, nursing students may feel unvalued, unsupported, and ultimately disempowered.

A study conducted by Bradbury-Jones et al. (6) found that it is important for nursing students to have the necessary knowledge and confidence and to be valued as learners in clinical practice. These are crucial components for developing empowerment. Importantly, knowledge and confidence are locked into a dynamic interplay, and from a nursing student’s perspective, empowerment cannot exist without knowledge and confidence; they co-exist. Lauder et al. (13) equated confidence with self-efficacy. The relationship between empowerment and self-efficacy was identified by Pearson (14), who found that if nursing students felt empowered, their levels of self-efficacy would increase, and ultimately, this could have a positive impact on patient care and students’ experience and competence in the clinical environment (6).

Empowering Students of Education

The NMC (15) standards for professional practice and behaviour stipulate that nurses should work with competence and confidence. Stayt and Merriman (16) surveyed 421 students regarding their perception of opportunities to practice clinical skills and level of supervision in their clinical placements. They concluded that a lack of empowerment through reduced opportunities to practice skills reduced work performance and students’ recognition of professional responsibilities was an overall threat to patient safety and the level of patient care. Stayt and Merriman (16) suggested that timely access to resources and support within both a university and clinical learning environments encourages confidence among nursing students, which in turn promotes higher levels of competence and increases patient care and safety. Conversely, a reduction in competence among nursing students is linked to poor levels of structural empowerment (17). Structural empowerment is where organizations facilitate access to resources and support that empower the workforce to work more effectively (17). Evidence has determined that education significantly increases psychological and structural empowerment across all dimensions (18). Liao and Liu (10) completed a cross-sectional survey of 300 senior nursing students undertaking clinical practice. A 95.3% response rate indicated a significant relationship between nursing students’ levels of structural empowerment and their overall competence in nursing due to having access to the right resources at the right time.

Numminen et al. (19) examined newly graduated nurses’ perceptions of the ethical climate of their work environment and its association with self-assessed professional competence, turnover intentions, and job satisfaction. The study found that self-assessed competence was strongly linked to empowerment (19). This relationship was later supported by Visiers-Jiménez et al. (20), with the additional finding that competence is specifically related to expertise and professional development during nurse education. Visiers-Jiménez et al. (20) highlighted that competence in a newly graduated nurse’s role development was a particularly important aspect of empowerment for nursing students. This suggests that to build confidence and competence and support empowerment throughout professional development, encouraging an open and transparent dialog where everyone feels listened to. The implications for both managers in clinical practice and nurse educators indicate that empowerment is facilitated by treating everyone as equals and encouraging open conversations from the beginning of a nursing student’s education and throughout their career (20). Additionally, Sharma and Sharma (21) found high levels of student empowerment in a Category A, NAAC-accredited premier nursing institute, suggesting that education can lead to increased levels of competency and assuredness.

Empower Nursing Students in Clinical Placement Settings

The NMC (15) stipulates that UK nurses should undergo 50% of their pre-registration nurse education learning theory and 50% in clinical practice placement settings. These clinical learning experiences are essential to practicing nursing care; they help build fundamental nursing skills, and nursing students can apply the theory taught in universities to the practice environment. Argyris and Schön’s (22) practice learning theory argues that without clinical learning experiences during formative education, nursing students will not have the opportunity to develop their tacit knowledge, confidence, and sense of empowerment for themselves and for their patients, which suggests that nurse educators and placement partners are in a strong position to encourage, nurture, recognize, and address nursing students’ empowerment needs (20). Additionally, Maslow (23) claims in his motivational hierarchy of needs theory that people need to be accepted, recognized, appreciated, and included to ensure self-actualization. Similarly, Larkin et al. (24) asserted that a sense of belonging is a universal human need. Sense of belonging has been widely researched in nursing and is an emotional response to feeling included, valued, and accepted (25). When students feel accepted in a workplace, the result is a positive learning experience, confidence, and motivation to learn (26) and thus empowers nursing students’ ability to socialize and form a strong professional identity (27).

Albloushi et al. (28) identified many facilitators and barriers to empowering nursing students’ learning ability during clinical placements. The study used an interpretive design to conduct semi-structured interviews with 16 Saudi nursing students about their sense of belonging during their placement. The findings support those of Lakin et al. (24), Levett-Jones and Lathlean (25), and Gerrard and Billington (26) who reported that when students are included, valued, and welcomed into practice areas, their sense of motivation to learn is enhanced. In contrast, students in the study by Albloushi et al. (28) reported that when they were not well prepared for placement by academic teams in education, a lack of participation and acceptance in placement. Additionally, language barriers affected the students’ ability to understand the requirements of the placement, which led to feelings of distress, anxiety, and disempowerment (28). These results demonstrate the need for nursing students to feel like they belong in the workforce and highlight the necessity for nurse educators to ensure that nursing students are well-prepared for clinical placements in all care settings. Moreover, evidence has shown that creating a healthy working environment and adhering to standard norms may foster the empowerment of nurses and nursing students, irrespective of the setting where they work (29). Fostering this sense of empowerment might be achieved by enhancing nursing students’ ability to recognize, understand, and communicate learning outcomes in all care settings. This will help enhance their ability to learn and take responsibility for their learning and may empower placement staff to understand and support their needs, with the ultimate goal of student’s ability to gain a sense of belonging to the workforce team.

The SBNH-L Framework to Enhance Empowerment in Healthcare

The SBNH-L framework to enhance the empowerment of healthcare professionals (30) was conceptualized from the original strengths-based nursing healthcare (SBNH) model (31) intended to guide healthcare staff in delivering compassionate and knowledgeable care. The SBNH-L (Figure 1) is a unique, values-driven framework to assist leaders and managers of healthcare teams in creating safe and equitable environments that recognize individual strengths. The framework is driven by core person- and family-centered care values of systems-thinking; uniqueness; health and healing; multiple perspectives and creating meaning; self-determination; goodness-of-fit; timing-readiness-learning; and collaborative partnerships (30).

The framework focuses on the innate quality of leaders using their attributes to empower those working in their teams to deliver safe and compassionate care to service users. Gottlieb et al. (30) summarized the SBNH-L framework as follows:

“SBNH leaders strive to be humble, self-aware, authentic, open-minded, compassionate, courageous, credible, curious, creative, flexible, and resourceful. They have integrity, imagination, and operate from a growth mindset. They strive to be engaged, collaborative, systems-focused, solution-oriented, and evidence-informed. These SBNH leadership qualities determine how the four foundational and eight core values are enacted”.

The SBNH-L was created to guide leaders to create an environment that enhances and encourages self-awareness and gives them the confidence to value their judgments and act upon them. The framework is reflective and asks questions of leaders such as:

1. What do I need to consider or think about when establishing a policy or directive in place? 2. How does my department or unit fit within a larger healthcare institution? 3. As a nurse manager, how does the organization foster autonomy and agency in a nurse manager? How do these policies impact my actions at the unit level? (27). Responding to these questions empowers leaders to recognize and value collaborative partnerships with staff that invite participation in decision making and enhances their value in the workplace. Collectively, these contribute positively to nursing students’ experiences.

Support Students in Raising Concerns

In the 1990s, a call was made to nurses to develop a strong voice and the willingness to speak out when necessary (32). This was reiterated in the Francis Report of 2013 (33) which recommended a duty of candor for healthcare professionals. However, Bradbury-Jones et al. (34) found that nursing students failed to speak out even when they witnessed unprofessional behaviour. One reason for this was that nursing students were unsure of their place and felt uncertain about how to escalate issues (35). The evidence suggested that this issue was reduced as nursing students progressed through education. However, a suggested cause for fear to speak out was the fear of reprisals from colleagues, which is supported by evidence from Brown et al. (35) who explained that the clinical area and the dynamics on the ward dictated how confident nursing students felt about raising any concerns. Further evidence suggested that bullying and incivility were rampant in clinical nursing education and that instructors must address these behaviours so that nursing students feel empowered (36). Through psychological empowerment, nursing students can learn to be more assertive (37).

In the professional environment, nursing students play many important roles to play; however, one of the roles is raising concerns. The NMC has provided information regarding the processes that should be followed when raising concerns. Preregistration nurses have a professional responsibility to put the interests of patients first and to act in the best interest if it is felt that service users are at risk (38). Regardless of the healthcare environment, concerns should be raised appropriately. Safeguarding the health and well-being of patients in care means working in their best interest and protecting them from abuse or neglect (38).

According to the Care and Support Statutory Guidance (39), there are many different types of abuse that nurses should be aware of

• Physical abuse,

• Domestic violence,

• Sexual abuse,

• Psychological abuse,

• Financial or material abuse,

• Modern slavery,

• Discriminatory abuse,

• Organizational abuse,

• Neglect and omission,

• Self-neglect.

According to the Care Quality Commission (40), it is of paramount importance for all healthcare providers to be aware of the warning signs of any type of abuse and that healthcare professionals, such as nurses, can escalate any concerns without fear of retribution or harm. Nursing students are in an excellent position to be able to see the warning signs as they may spend more time with the patients. Therefore, part of the education process must be to ensure that nursing students are confident in speaking up when necessary (41).

Nursing students may not always easily report concerns in the practice environment due to a belief of disloyalty to the team or fear of reprisals from a practice assessor or a practice supervisor. Here are some principles outlined by the NMC (38) that nursing students should follow when raising concerns:

• Inform their practice assessor/practice supervisor, tutor or link lecturer immediately if they believe a patient is at risk of harm.

• Seek immediate help from an appropriately qualified professional if someone in their care has suffered any damage for any reason.

• Seek help from their practice assessor/practice supervisor, tutor, or link lecturer if people indicate that they are unhappy with their care or treatment.

The adoption of these principles could result in concerns being investigated. It is important to note that it is the responsibility of nurses who have received these concerns to take action. Should action not be taken, a nursing student can further escalate concerns to the ward manager, who in turn should take immediate and expeditious action. It is also important for nursing students to inform their link lecturers in the education setting about the concerns they have raised in practice regarding patient care and treatment to obtain support from link lecturers.

Empowerment Beyond Preregistration

Evidence from the literature suggests a significant positive relationship between nurses’ perceptions of empowerment and patient satisfaction (42). This revealed that nurses with a Master’s degree or higher perceived themselves to be highly empowered, which in part also took into consideration rank and experience, with more experienced nurses having higher graduate qualifications (42). Education and experience are factors that increase confidence; therefore, pre-registration nurses should aspire to continuously self-actualize throughout their career. This may lead to the empowerment of nursing students, who can deliver and provide high-quality person-centered care for all ethnicities, including diverse communities (43).

According to Sensenig (44), through successful collaboration, nursing students benefit from working with culturally diverse, underserved populations while also having a positive effect on the health of the local community. Haycock-Stuart et al. (45) also recommended the involvement of service users and carers in providing feedback to nursing students about their clinical practice. Further evidence indicates that nursing care should be developed to enable nursing students and service users to collaborate to co-create care and support regimens. However, nursing students may have to give away power to patients (46). This would allow patients to not entirely depend on them while also ensuring that nursing students prevent stress and burnout from feeling overworked (46).

Christensen and Hewitt-Taylor (47) argued that empowering patients contrasts with the traditional healthcare stance and requires patients to want to take control and take responsibility for their own health. Hewitt-Taylor (48) noted that patient empowerment can aid in addressing any power imbalances between patients and healthcare providers, where nurses and indeed nursing students can empower patients to act in their own best interests if they are being subjected to coercive or controlling practices by healthcare staff. However, patient empowerment brings with it responsibility and greater autonomy, resulting in discussions on potentially difficult issues of an individual’s responsibility for their own health and how their decisions may affect others (48). Christensen and Hewitt-Taylor (47) warned that if patient empowerment is to become a reality, then the attitudes and values held by staff and patients, as well as overt behaviours, must be congruent with the principles of empowerment. It is the responsibility of nurses, including nursing students, to empower patients to take control of their care. Empowering patients will enable them to further develop their self-awareness skills and enable them to become equal partners in healthcare.

Positive Effects on Nursing Students

A recent study determined that empowering nursing students with competency-based clinical education has a positive impact on their attitudes, knowledge, advocacy, and care strategies when dealing with vulnerable and underserved populations (49). The results of another study demonstrated that case-based learning can lead to feelings of empowerment for nursing students, as well as develop critical thinking and stress management skills and acquire professional competencies (50). Education that challenges and empowers nursing students can also enable them to take action toward Sustainable Development Goals (51), and they are increasingly showing job satisfaction, productivity, and high standards of nursing care (21). Emrani et al. (52) concluded that incorporating service-based learning techniques into clinical education programs is essential for empowering nursing students. Other studies have also reported that educational programs are vital for developing a positive self-image and improving empowerment among nursing students (53, 54).

Summary of Positive Empowerment Strategies for Nursing Students, Nurse Educators and Learning Environments

This discussion paper has demonstrated that nurse educators are in a good position to ensure that student nurses are well supported to develop confidence and competence and enhance empowerment. The knowledge gained from this discussion is important for nurse educators, students, and practice partners who support clinical placement to enhance the empowerment of nursing students throughout nurse education and clinical practice. Table 1 summarizes the strategies discussed throughout this work.

Conclusion

Empowerment enables nurses, including nursing students, to possess the knowledge and confidence to increase both nurse and patient autonomy, which in turn positively affects patient care, development of critical skills, professional competencies, and confidence. Nursing students must feel valued and treated with respect, work in an environment that is open and transparent, and have access to adequate resources and support; otherwise, oppressive power structures may prevent them from speaking out about poor care and fear reprisals from senior healthcare staff. In contrast, the literature has suggested that nurse-led environments, in conjunction with service users, benefit nursing students, patients, and local communities. Education plays a vital role in enabling nursing students to feel empowered. This article has contributed to the literature by collating and summarizing the history and importance of empowering nursing students, using evidence and suggestions from various studies.