Empowerment is the ability of a person to act professionally and having control over their performance. Moreover, empowerment is the opportunity of a person to have access to resources, information, opportunities and support needed to achieve organizational goals in performing their duties [1]. Empowerment is very important for nurses as it is argued that high quality care is significantly associated with an empowering workforce that meets the professional standards of care. Whereas, a powerless nurse is always depressed, having low self-esteem, and lacking the ability to decide in critical situations [2]. Today, Healthcare services need to focus on this integral component of empowering staff nurses during these times of scant resources and growing demands of providing safe, and quality services. The literature review revealed that majority nurses are understated in the organizational ladder. Therefore, diminished their capacity to take part in decision making and an active role in organizational structure and formulating strategies regarding quality care. Eventually leads to low self- esteem, emotional instability, and lack of commitment in services [3]. Empowerment in nurses is vital for both the health care system and society as a whole. For the health care system empowered nurses results in more job satisfaction, increased nurse retention, and ultimately enhancing their commitment towards their patients. For society empowered nurses to become a source of motivation for others and provide more compassionate care through community coordination and mobilization [4].  However, in reality all over the world nurses are facing problems including discrimination, gender bias, and disrespect. The situation is even worse in developing countries like Pakistan where nurses are quite powerless and being oppressed by society. Here’s still nursing is a profession that is facing the least opportunities and access to information and resources. That is evident through reporting of lack of confidence and low self-esteem among nurses [5]. That is affecting their ability in providing care to the patients and their role as health care providers. Hence, it is imperative to assess the nurse’s knowledge, understanding and level of empowerment. Therefore, effective strategies will be made to empower nurses in clinical practice. Consequently, leading towards organizational transformation of providing quality care at bedside. The ultimate purpose of this project will be to generate awareness among nurses regarding their hidden area and its contribution in their job performance. For this purpose the project utilized the basic nursing process phases including 1) Assessment, 2) Planning, 3) Implementation, and 4) Evaluation.

Assessment Phase

Assessment is the first and foremost important step for the success of a project. As in the assessment phase essential data is gathered to examine the exact situation and the extent to which intervention is needed. It involves two steps subjective and objective data collection. Subjective data related to the verbal statements that are directly reported from the participant. Whereas, objective data is the data driven from keen observations that the researcher made self-observations to find the truth. Critical thinking skills are essential to assessment, thus the need for planning an intervention based on assessment phase [6].

Subjective Data Collection: A pre-assessment survey was conducted in Jinnah hospital in the month of April, 2020. All the registered nurses from all educational levels and both genders were including in the survey. The survey includes the participants through purposive sampling and includes head nurses and staff nurses from Medical, Surgical, Neuro, Cardiology, Gastroenterology, Psychiatry, and emergency department. A sample size of 20 staff nurses and 5 head nurses took part in survey. A pre-assessment questionnaire regarding general questions extracted from Literature review and the Conditions for Workplace Effectiveness Questionnaire-II (CWEQ-II) tool was used to assess nurses’ knowledge and level of empowerment in clinical setting [7]. The questionnaire is attached in appendix B. A brief introduction and purpose of this survey was briefly described to all the participants by the researcher. The questionnaire is having the option of yes, no, and, I don’t Know scale and including questions regarding:

• What is empowerment?
• What are the things necessary for empowerment?
• Do you feel empowered at your workplace?
• Do you have an access to adequate resources necessary for your job performance?
• Do you have an access to information at work place?
• Do you have an access to opportunities at your workplace?
• Do you receive any reward or appreciation for your efficient work at your job?
• Do you receive any support and flexibility from your coworkers and manager?

All the participants including in the pre-assessment phase fill the questionnaire and majority responding that they do not have adequate knowledge of empowerment and majority responding that they did not know what things are necessary to make them empowered at work place. Mostly participants said that they have no access to information, resources, opportunities and asking the support and flexibility at workplace. The pre-assessment knowledge of participants is shown in (Figure 1).

Figure 1: Pre- Assessment Knowledge.

Out of 25 only 3 said they have knowledge while a 15 said they have no knowledge and 7 said they did not know about it.

Figure 2: Feeling Of Empowerment.

Regarding the feeling of empowerment only 4 participants said yes they feel empowered at work place and 17 said they did not feel empowered while 4 said they did not know. Overall, the above results showed that majority nurses have no knowledge regarding empowerment as they were even unaware of their rights to have access to information, support, resources and opportunities.

Observation Data Collection: An observation was made with the help of facilitating team that include three students and two teachers and an observation report was submitted after one week. The report is attached in Appendix C. The team members visited the emergency, medical, surgical, ortho, psychiatry, and gynaecology wards and their observations were on the following:

• Active participation in decision making in relation to patient health care needs
• Demonstrate Autonomy and problem-solving approach towards patients.
• Play active role in protecting patients’ rights.
• To operate itself with enthusiasm
• Having access to resources, information and opportunities regarding professional growth and development
• To receive appropriate reward and appreciation at work place
• Working in supportive and motivational environment.

The report gives the observations that in the pandemic of COVID-19 they don’t have access to adequate information regarding self-protection. They don’t have access to adequate resources, and don’t be rewarding for their services. Essential equipment necessary for their protection is scant and no one take any notice. They are not obliged in their services and do not find any flexibility in their services. They are not observed empowered at their work place.

Planning Phase

The planning stage is started through formulation of goals and their expected outcomes. Goals are selected according to the standard of specific, measurable, attainable, realistic, and time oriented [8]. In the planning phase first goals are set and then make strategies to achieve those goals. The resources needed for the implementation could be identified in the planning phase. Adequate planning is crucial for the sustainability effects of the outcomes [9]. The main objective of this project was to give awareness regarding empowerment in clinical practice and shift focus towards generating effective strategies through which nurses should feel and gain empowerment. It is argued that empowerment depends on the degree of having formal and informal power. Formal power is secured through means of flexibility, support and creativeness art work place. While Informal power is synthesized through healthy relationship, team coordination, and support from peers [10]. The project team first planned a meeting with chief nursing superintendent in the hospital and a second meeting was planned with managers of each individual ward. A plan was made to empower a group of bedside nurses to develop a formalized process to monitor and evaluate nursing practice in relation to patient outcomes, nurse-sensitive and hospital quality indicators, and care delivery. It was anticipated that the project development team will help identify and rectify components of structural empowerment that are deficient within the current facility. Over time, this will lead to nursing empowerment, monitoring, and evaluation of nursing practice with improved patient care quality, safety, and outcomes. The initial step was to plan educational interventions for nurses at their workplace with the collaboration of project team. A plan of educational intervention on empowerment was made to give knowledge and awareness of nurses regarding their fundamental rights. As knowledge is considering prerequisite for the bringing up change [11]. Therefore, educational intervention through power point presentation with additional aids of charts and pamphlets were planned. All the charts and presentation have the content on empowerment. A team of three students and two instructors were planned to include in the facilitation process of workshop. A small role play was planned to enhance understanding and interest of the participants. A half hour question answering session was planned and at the last a 15minute feedback session was planned. A post assessment knowledge regarding empowerment is also planned for evaluation. The additional strategies and recommendations were planned to enhance the program strength. After intervention process development, the nurses’ perceptions of structural empowerment or access to information, resources, and support were reevaluated. The learning plan for educational intervention is given below:

Topic: Nursing Empowerment

Group: Nurses

Place: College of Nursing Auditorium (AIMC)

Duration: 1 & 1/2 hour

Method of Teaching: Lecture-cum-discussion

Teaching Aids: Multimedia, flash cards, charts, role play

General Objectives: After completion of the lecture participants gain knowledge and awareness regarding empowerment. They acquired the knowledge regarding different sources of empowerment. This awareness eventually leads to recommendations and making effective strategies for gaining empowerment at workplace.

Specific Objectives

• What is empowerment?
• What is the difference between power and empowerment?
• Briefly describe Kanter’s model of Empowerment
• How nurses can be empowered at work place?
• Describing the factors that effect on Empowerment
• Identify the sources of empowerment.
• Describe the process of empowerment.
• Describe the relationship of empowerment and quality of work.

Table 1: Learning Plan for Educational Intervention.

Implementation Phase

Implementation is the most crucial phase for carrying plan into action. The phase is important as the successful implementation leading to the outcome that is preset in the planning phase. The goals achieved further evaluated in the evaluation phase to meet the standards or not [11]. Structural Empowerment is determined by the power to get things done through the utilization of information, support and mobilization of the resources. Lines of supply is maintained through the resources (e.g. materials, money, staff, etc.) needed to achieve organizational goals. Accessing information refers to having the knowledge, information, and/or data needed to do the activity being planned after assessment phase. The lines of support refer to allowing for innovative and effective decision-making to take actions that accomplish the goals of the project. While Kanter described these sources as a means of empowerment and improved performance [10]. By utilizing all the above line of supply, information, and support the teaching was implemented in the college of nursing auditorium at a predefined time of 12:00 to 2:00pm. The time was selected after discussion with participant’s convenience. A total number of 30 participants in which 10 head nurses and 20 staff nurses were inviting in the workshop.

• Tool for post assessment is attached in appendix B.
• 2 Charts images are attached in appendix C
• Pumphlets attached in appendix D.

The implementation plan is given below:

Table 2: Implementation of Learning Plan for Educational Intervention.

Venue: College of nursing Auditorium                                                                                                       Time: 12:00pm-2:00pm

Evaluation Phase

This final step of the nursing process is vital to a positive outcome. Whenever to intervene an intervention the essential step is the evaluation of the outcome that meets the desired standards of planning [8]. Evaluation phase was conducted soon after the intervention end an half an hour of answering question session was conducted to identifying the participants understanding. After that feedback was conducted in which each individual participant was giving a chance to provide their valuable suggestion and recommendations. A post- assessment test was conducting to reassess the knowledge about empowerment. The study found that in the post assessment test out of 30 participants all participants said that they have knowledge about empowerment, its resources and its process. In the feedback session out of 30 participants 25 said that they are now confident to the process of empowerment.

Figure 3: Post assessment knowledge.

Out of 30 participants 27 identify successfully the sources of empowerment.

Figure 4: Sources empowerment.

Regarding the effectiveness of the teaching program 25 said it is very much effective and 5 participants said it is somewhat effective and need further improvements.

Figure 5: Feedback about teaching program.

The studies conducted in short time and include only female nurses. That could effect their implication when considering males in the workplace. Further the participants were small in number. Therefore, there is need to further conduct in with more participants to generate awareness regarding empowerment in clinical setting.

The study proposes the following recommendations:

• First nurses should be empowered structurally and psychologically and this could be possible when nurses have adequate access to information, resources, support, and opportunities of learning and professional development. Timely access to information regarding organizational policies and job descriptions will make them confident to make decisions in such situations. Access to adequate support and resources gives a sense of security.
• The health care system is a diverse environment that is continuously changing and requires effective decision-making skills among nurses. Nurses should be skillful in clinical decision making to quickly analyze the situation and make an effective plan of care that meets the patient's needs in an effective way [2]. Through an effective decision-making ability, nurses should assess the complexity of the situation and take appropriate actions accordingly. This could enhance nurse-patient therapeutic relationships and increased patient satisfaction additionally with a sense of empowerment.
• Education plays a key role in professional growth and development. An in-service education program refreshes nurses' knowledge and enhances their confidence during the provision of patient care. An empowering educational model should integrate into clinical practice give nurses an opportunity for professional grooming and achieving mastery of the skills [7].
• Reflection in nursing practice plays a significant role in professional nursing practice and learning in clinical practice. Through reflection, nurses learn critical thinking and analyze the situation in a new direction and make innovative strategies to handle situations of conflicts. It is evident in research that reflection help in learning increases awareness among nurses to implement new strategies to solve problems and take an initiative to change the practice through the innovative plan of action [5].
• Nursing managers have an important role in empowering their subordinates. They promote a healthy facilitative environment in which high-quality patient care would be possible. They play an essential role in empowering nurses to perform their duties to their maximal level of excellence. They should make effective strategies that make it possible for the participation of every staff nurse in decision making. A participative leadership style of nurse manager promotes their staff empowerment and increases their quality of work and patient care outcome [3].
• A trusting transformational relationship of nurse managers with their staff nurses is crucial for their mental peace and quality care. An environment that promotes decision making skills in a critical situation and effective support from managers and administration enhance confidence and improve quality care. However structural empowerment is needed for decision making [6].
• In the last but not least frequent workshops should be conducted to refresh knowledge in clinical practice.

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