Power is ever present and particularly evident in the clinical learning environment and nursing. Kuokkanen et al. (2007) suggested that power and empowerment are interwoven, and that in order to understand empowerment one needs also to understand power. Likewise, Bradbury-Jones et al. (2007) suggested that the difficulty in understanding power and its relationship to empowerment is that they both take on different forms in different contexts. Power may be viewed as an organisational tool or a personal attribute. It is also fluid and can change depending on the situation, which makes it difficult to describe and define.
It is evident, then, that power can be viewed from many perspectives and is part of all facets of life. Manojlovich (2007), for example, advocated viewing power from a historical, educational and nursing practice perspective, while Kuokkanen and Leino-Kilpi (2000) proposed that power and empowerment can be viewed from
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three main perspectives: critical social theory, organisational and management theory, and psychological theory perspectives. In a contemporary analysis of power, Peltomaa et al. (2013, p. 586) stated that:
“Nursing power and empowered nurses go closely hand in hand”
This reinforces the importance of power in this discussion of empowerment and its importance in understanding the complexities of empowerment. Mathews and Scott (2008 p.131), on the other hand, advocated a postmodernist approach, drawing on the work of Foucault as being preferable to “grand theories” within a nursing perspective, as this is able to accommodate the fluid and dynamic, ever- changing concepts of power in a nursing context. From an emancipatory or critical social theory perspective, there are many reasons proposed in nursing literature for why nursing has traditionally been viewed as a profession that is dominated, oppressed, and lacking in power. Wuest (1994, p.357) suggested it is because historically, nursing was viewed as “women’s occupation” – a domestic role fulfilled by women. Educating nurses in hospitals also served to further contribute to the low status of the profession (Manojlovich, 2007). According to Rafael (1996), nurses view power as a masculine trait and, in a predominantly female profession, many are reluctant to access power. Manojlovich (2007) suggested that the reluctance of nurses to embrace their power and use it may contribute to their lack of control over their practice. Benner (1984) examined power in the provision of care for the patient, and refers to the transformative and healing effects power can have for the nurse and patient. Wuest (1994) suggested that nurses’ fail to appreciate their own knowledge gained through the provision of care and have focussed instead on the acquisition of power through professional statutes. It would therefore appear that power and powerlessness are inextricably linked and connected to care and nursing practice; and as acknowledged by Kuokkanen et al. (2007), the relationship between power and empowerment is complex. Thus, in order to examine the relevance and meaning of empowerment, power also has to be considered (Bradbury-Jones et al., 2008).
According to Kuokkanen and Leino-Kilpi (2001), power within the organisational context is the by-product of individual behaviours and relationships between
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individuals. Bradbury-Jones et al. (2008) suggest that power is also shaped by its context. Hierarchical structures and an acknowledgement of a power legacy in healthcare have been an established presence in the nursing literature (Suominen et al., 1997: Bradbury-Jones et al., 2007) Interestingly, ’historical legacy’ emerged as a key theme in an Irish study (DoH & C/DCU, 2003), and Kuokkanen and Leino-Kilpi (2000) suggested that empowerment (or lack of it) is associated with hierarchical and authoritarian organisations. While Gilbert (1995) noted that a lack of empowerment is directly related to the negative and authoritarian concept of power experienced by many nurses. Davies’ (1995) stated that nurses frequently perceive their contribution as being “voiceless” leading one to question nurses’ self-perception or self-esteem. Scott et al. (2013) in an Irish study stressed the importance of inclusion of nurses in strategic committees to give nurses a voice and to empower nurses within their organisations. This lack of voice or lack of power, that leaves nurses feeling powerless despite their important role in healthcare provision, has consequences at political, social and educational levels. An empowered workforce is necessary for compassionate high quality patient centred health care (DoH & C/DCU, 2003). Hierarchical power structures in healthcare stifle empowerment of staff and this has resultant implications for healthcare.
Lukes (2005) described power as having three dimensions: overt, covert and institutionalised. Institutionalised power is not maintained by single acts, but rather through socially-constructed norms of the institution. Therefore, those in subordinated positions become accustomed to, and socialised in, the ways of the institution. This can perhaps explain why nurses (DoH & C/DCU, 2003) do not voice their concerns, and feel that their voices are not listened to. Control and autonomy over work-related matters are important in nursing. These concepts are associated with job satisfaction, and are viewed as contributing to the overall efficacy of a nurse’s role (Ellefsen & Hamilton, 2000). It would appear, then, that if nurses as subordinates neither have nor take control, their sense of job satisfaction can be adversely affected. Spreitzer (1995) maintained that factors such as self-esteem, impact, and job satisfaction are all part of empowerment. This further demonstrates the connection between power and empowerment, and the extent to which both concepts are inextricably linked.
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From the individual or psychological perspective of an undergraduate nursing student, it is important to understand the hierarchical and sometimes fraught environment in which they will practice their nursing skills. Undergraduate nursing students need to be empowered to have a voice, and to feel that their contribution is being listened to in order to encourage and stimulate their feelings of self-worth and to acknowledge their important contribution. Kuokkanen et al. (2002) suggested that the use of empowerment to increase the power of subordinates is where the root of empowerment is traditionally embedded, while Decker and Shellenbarger (2012) advocated that empowerment and education are key contributors to the promotion of a healthy work environment for undergraduate nursing students. Laschinger et al. (2010b), in a study of new graduate nurses, found that empowering work environments lessen the effect of bullying. It is evident therefore, that power and empowerment can be viewed as having a close relationship, whether interdependent or connected.