Factors Influencing Nursing Students’ Empowerment: A Literature Review

Aim: The purpose of this literature review is to locate the available literature that addresses the factors influencing the nursing students’ empowerment. Background: Nursing students’ empowerment is an essential element to enhance the learning process. Nursing students’ learning experiences in the classroom and in the clinical placement play vital role in their empowerment. Data Source: A review of relevant literature using the following databases: CINAHL, ERIC & EBSCO. Methods: A literature review of, peer-reviewed research, Master/PhD dissertations full text and published on the listed databases between (2003-2019) was done. Results: A final review of 16 studies was included, quantitative and qualitative studies that discussed the factors that may affect nursing students’ empowerment were included in this review. Conclusion: Viewed articles revealed that nursing students’ empowerment may be affected by many factors. According to previous literature and according to the authors’ perspective, the retrieved articles categorized as followings: intrapersonal empowerment, learner orientation to learning, teaching-learning experiences, and the learning environment that influencing the learners’ empowerment.


Introduction
Empowerment is a concept developed in the last five decades. Empowerment at the beginning was discussed as manager-employee relationships, and how the managers can create trustful relationships with their employees. Then, the concept of motivation came into an organizational context to enhance these relationships until it developed to empowerment [1]. Cangaro (1989) described

Search Outcomes
The primary search at the database retrieved 645 articles. Then the duplicated and unrelated articles were removed. After screening by titles 17 articles were removed because they did not meet the inclusion criteria. Then articles were screened by abstract and the remained articles were (n = 205). Next, after full paper reviewing 75 studies remained. Final number of articles included in this review and met the inclusion criteria were 16 studies. The searching strategies are illustrated in (Figure 1).

Results
The retrieved literature related to the factors that may affect nursing students' empowerment were categorized under four sections. The first section defines and describes intrapersonal empowerment in the literature within the nursing education context. The second section describes and illustrates the related factors of learner orientation to learning. The third section defines and illustrates the related factors of teaching-learning experiences. The last section defines and describes the learning environment that influence the learners' empowerment.
The retrieved studies are summarized in (Table 1).  Learners' characteristics.
The results showed that the internal level of knowledge and confidence of the students are the most common factors that may affect their empowerment level Houser & Frymier (2009) To investigate the learner and teacher characteristics in the classroom that may affect the learners' empowerment.
The teacher clarity and convenient communication with student enhance the sense of learner empowerment. The student motivation to learn and his individual characteristic as learning orientation has a great influence on the sense of empowerment. Both the teacher characteristics and learner characteristics are essential to increase the sense of learner empowerment.
Kirk, et al. (2016) To identify both intrapersonal and environmental factors that predict increased empowerment and outcomes associated with empowerment.
Clinical placement characteristics.
The students' behavioural and academic characteristics indicate that students who reported a high level of intrapersonal empowerment are less likely to be engaged in trouble, less likely to skip class, more likely to participate in activities extracurricular, and get higher grades. Liao  Learners' attitudes toward learning.
The most common source of stress is the assignment prior to the clinical training. Stress was found to be less in senior nursing students in comparison with junior students. Students reported that the stress level decreased with their academic progression, and how they become more confident of their knowledge and skills. Educators' characteristics.
The results of this study highlighted the role of the teacher beyond presentation a class. Teachers should open an interactive and collaborative channels with students to improve the desired learning outcomes.

Cakir (2015)
To assess the teacher's attitudes in the classroom 322 A cross-section design.
The authoritarian attitudes of the teacher are to control and nurturance in the classroom. When teacher uses an authoritarian attitude by controlling the classroom and in nurturance context; they feel empowered and thus enhance their learning process. Well-established, goal-oriented teaching process would produce cooperative, rapport relationship between teacher and student, and successful learning outcomes. Schrodt et al. Educators' characteristics. Teacher-student relationship.
The results showed that the most type of power used is the referent power. Referent power used when the teacher shows the commitment to the class and build rapport relationship with students to improve the students' perception toward the class and enhance their participation in the class activities.
Learning environment Al Nasseri, et al. (2014) The literature review identified impact of the student-teacher relationship on the students' learning process Clinical instructors' capabilities. Teacher-student relationship.
Adequate preceptors' capabilities to improve the theory-practice gap, leads to a better clinical learning environment. Adequate teacher-student relationship with respect has a great impact to decrease students' stress level, give support for students to accomplish their goals, increase their motivation to learn, and improve their achievement To explore the factors that enhance or inhibit empowerment development during the clinical placement.
Clinical placement. Organizational characteristics.
Clinical learning environmental culture such as language, values, beliefs, attitudes, uniform, rules, and practices provide more understanding to nursing culture. The importance of organizational culture is to facilitate nurses, educators, and students' access to resources at the organization to be empowered.

Ledbetter & Finn (2013)
To investigate the influence of technology use in the classroom 294 Correlation design.
Teaching methods. Organizational characteristics.
Using technology in teaching through online communication with the teacher out of class, which reflect positively on instruction learning outcomes. Polices supported the use of technology moderately in the classroom associated strongly with moderate to high -level intrapersonal empowerment students' level.
Murphy, et al. The clinical placement with high independence in performing nursing skills, and staff cooperation to facilitate learning opportunities improve their satisfaction level at that place. When they were practicing nursing skills with the ward's staff, and hands-on-skills improve their performance during the clinical training Peterson, et al. (2014) To assess the impact of the organizational characteristics on students' empowerment level 423 A survey. Learners' characteristics.
The students who show an adequate level of empowerment had a high sense of community, good feelings of being valued, and experienced diversity of faculty.

Intrapersonal Empowerment
A qualitative longitudinal study explored nursing students' empowerment in clinical practice, the study had started at first level to third level [9].  self-reported grades, and expectation for future academic attainment). The classroom factors strongly predicted the students' intrapersonal empowerment.
Teacher-student relationship was manifested as the teacher use of power, teacher use of referent power and the student sense of community. Teachers' use of coercive power was associated with lower intrapersonal empowerment level of students. Moreover, the students' behavioural and academic characteristics indicated that students who reported a high level of intrapersonal empowerment were less likely to be engaged in trouble, less likely to skip classes, more likely to participate in extracurricular activities, and get higher grades.
Another Chinese study investigated the 300 senior nursing student' level of empowerment and its relation with clinical competencies [7]. The students re- Houser & Frymier [12] investigated the learner and teacher characteristics in the classroom that may affect the learner empowerment. Two hundred ninetyseven senior students at South western University completed the questionnaires.
The results indicated that the teacher clarity and convenient communication with students enhance the sense of learner empowerment. Similarly, student motivation to learn and his/her individual characteristic and learning orientation has a great influence on the sense of empowerment. This study predicted that both the teacher characteristics and learner characteristics are essential to increase the sense of learner empowerment.

Learner Orientation to Learning
Personal characteristics during learning affect the learning process. Stress raised out by learning requirements is one of the factors that may alter students' clinical learning process [13]. It affects students' ability in problem-solving, decision making, and affect their self-esteem level. Chernomas Wanda & Shapiro [14] emphasized the importance of clinical placement, instructor's role, and assignment preparation on fourth-year nursing students stress level and their expectations from the clinical experiences. A Jordanian study assessed the stress sources in the clinical environment among nursing students [15]. It assessed the stress types and sources, and coping strategies of 597 nursing students from two public universities in Jordan. The most common source of stress was the assignment prior to the clinical training. Stress was found to be less among senior nursing students in comparison with junior students. Adult Health Nursing course I (second year) was associated with a higher level of students' stress in comparison with the Advance Nursing Training course (fourth year). Students reported that the most common coping strategies used to overcome these stressors were: problem-solving, keeping optimistic, and transference. Students reported that the stress level decreased with their academic progression as they become more confident of their knowledge and skills. This study showed that, with experience the students feel independent in the clinical environment and their capabilities to cope with stressors is enhanced and their learning outcomes are improved.
Unstructured interviews of 16 nursing students to describe the clinical environment in relation to clinical learning experiences were conducted in Taiwan. The students reported that they were appreciated by their teachers as learners. They stated that the feeling of appreciation encourages them to show positive attitudes toward learning [16]. Also, self-directed students, who are aware of their limitations and potential had a sense of responsibility toward learning. This study emphasized students' role and their ability in improving their learning outcomes [16].

Learning-Teaching Experiences
The terms "clinical instructors" and "clinical preceptors" which were used in nursing research interchangeably, referred to the nurse educator who teaches in  [17]. The teacher plays a strong role in learning-teaching experiences, thus teachers' attitudes toward students in the classroom or in the clinical area and their attitudes in the teaching process, have a great impact on students' learning outcomes. Students-faculty members relationship was assessed in Jordan, at a public university as perceived by the students [18]. The students reported positive learning outcomes (better academic grades) when they interact more with their teachers after the classroom to discuss courses and to discuss further issues.
The results of this study highlighted the role of the teacher beyond class presentation. The study concluded that teachers should open an interactive and collaborative channels with students to improve the desired learning outcomes.
Furthermore, support from the teacher in the classroom and clinical environment makes learning a desirable experience [16]. Well-established, goaloriented teaching process would produce cooperative, rapport relationship between teacher and student, and successful learning outcomes [16]. The teacher-student relationship is of considerable value to enhance learner empowerment [19]. The empowered students are more likely to recognize the meaningfulness of the course, feel more sense of self-efficacy and competence to complete the tasks, and ability to identify the impact of the course. Schrodt, P., et al. [19] assessed how teachers' evaluation (power use) can predict the learners' empowerment. The results showed that the most type of power use within the five types of power that predict the learner empowerment is the referent power. Referent power is reflected when the teacher shows the commitment to the class and builds rapport relationship with students to improve their perception of the class and enhance their participation in the class activities.
On the other hand, the teacher authoritarian attitudes in the classroom were assessed by university students [6]. The authoritarian attitudes of the teacher are to control and nurture students in the classroom. The students reported that when they perceived that the teacher uses an authoritarian attitude by controlling the classroom in a nurturing context, they felt empowered and this enhanced their learning.
Jordanian nursing students perception of their clinical instructor's role at clinical setting were described by Hayajneh [20]. The students reported that particular clinical instructors' characteristics were perceived as motivating for them at clinical setting to learn. Also, they reported that the presence of the clinical instructors at the clinical setting adds a sense of relaxation and support for them. Students appreciated the clinical instructors' effort at the clinical settings; they described how clinical instructors act in a unique way with them. All these behaviors affect the clinical learning experience positively, and the students achieved their desired learning objectives.

Learning Environment
The learning environment for nursing students is a combination of clinical learning and classroom learning.The clinical learning environment (CLE) is the  [21]. The classroom learning is more structured than the clinical learning [22]. Identification of the factors that influence the clinical learning environment help to implement strategies to enhance desirable learner outcomes. Few but not limited studies focus on the impact of a learning environment, assessing new learning methods, and assessing the learning culture to enhance learning motivation [17] [23] [24] [25].
The literature reviewed the impact of the student-teacher relationship on the students' learning process [17]. The reviewed studies indicated that preceptor's capabilities improve the theory-practice gap, which leads to a better clinical learning environment. Also, adequate and respectful teacher-student relationship has a great impact to decrease students' stress level, give support for students to accomplish their goals, increase their motivation to learn, and improve their achievement. Thus, it would affect positively the students' learning outcomes.
Technology posses students to enhance the learning process, teachers strive to administer new innovation into teaching instructions to improve the learning instructions' outcomes. Ledbetter & Finn [26] investigated the influence of technology use in the classroom at South north University students and its effect on the students' intrapersonal empowerment level. The study used technology in teaching through online communication with the teacher out of class, which reflected positively on learning outcomes. The results revealed that policies that encourage the use of technology moderately in the classroom lead to strongly with moderate to high -level intrapersonal empowerment students' level.
Students would feel empowered when they reached to their expectations, they describe themselves as meaningful in the class, competent at class activities, and their activities have an impact in the class. They could feel the sense of empowerment. The important issue is how the teacher encourages students to reach a sense of empowerment. The teacher should be creative and improve the learning environment to enhance the students' intrapersonal empowerment level [26].
A study was conducted on undergraduate students and directed to find out major obstacles they may face during clinical learning experiences [23]. Five hundred, third-year undergraduate nursing student at Wales/United Kingdom were asked to assess three different clinical placement during that year. Students reported that the clinical placement with high independence in performing nursing skills, and staff cooperation to facilitate learning opportunities improve their satisfaction level at that place. They reported that they were practicing nursing skills with the ward's staff, and hands-on-skills improved their performance during the clinical training [23].
Organizations such as schools, strive to cultivate their resources and capabilities to be described as an empowered organization. The empowered organization's characteristics are described to facilitate the access to information and diversity of faculty [24]. Peterson, Farmer, and Zippay assessed the impact of organizational characteristics on students' empowerment level. The results re-Open Journal of Nursing flected that the students who show an adequate level of empowerment had a high sense of community, good feelings of being valued, and experienced diversity of faculty. In this study, the sense of community is the result of students' access to information, had the opportunity to participate in extracurricular activities, and practice decision-making skills in some teaching issues.
The power in the clinical environment is the effective use of resources to get a sense of empowerment. The ward/unit culture contributes to nursing students' experience in clinical placement. Clinical learning environmental culture such as language, values, beliefs, attitudes, uniform, rules, and practices provide more understanding to nursing culture. The importance of organizational culture is to facilitate nurses, educators, and students' access to resources at the organization to be empowerment. This condition is associated positively with nursing students' outcomes (managerial support, good student and healthcare providers relationship, higher patient care quality, and higher students' satisfaction level [25]. Clinical training plays an important role to facilitate the implementation of the desired learning objectives. The environment, instructors, and staff work collaboratively to facilitate learning opportunities to develop their knowledge, skills, and clinical teaching [27].

Conclusions and Recommendation
The reviewed literature illustrated the comprehensive definition of empowerment within the nursing students' context. The reviewed articles showed the importance of empowerment as personal characteristic, and the personal factors that may affect it. And that, the empowerment is affected by the organizational structure and culture. The reviewed articles supported that the helpful and supportive learning environment is an empowering environment in addition to intimate teacher-learner relationship. It also clarifies the major factors that may influence nursing students' empowerment level. Additionally, it clarifies how these factors may influence on nursing students' learning process and desired learning outcomes. The reviewed articles showed the essence of nursing educators' capabilities to empower students through building rapport relationship, supporting them, and facilitating learning opportunities.
The classroom learning and clinical learning are essentially simultaneously; as known, the nursing student spends the majority of their learning experience in the clinical environment.
The learning placement plays strong role to create learning chances for nursing students. The clinical instructors, administrators, and decision makers in the teaching hospitals should facilitate adequate clinical placement for nursing students to achieve their goals and objectives of required curriculum. Thus it will have positive impact on their comprehensive clinical skills, decision-making, self-esteem, problem-solving skills, and on patients' care. In addition, the ward staff and other healthcare providers should provide support and the available learning opportunities for nursing students during their clinical learning.