Journal of Nursing Education

Major Article 

Effects of Clinical Practice Environments on Clinical Teacher and Nursing Student Outcomes

Yolanda Babenko-Mould, PhD, RN; Carroll L. Iwasiw, EdD, RN; Mary-Anne Andrusyszyn, EdD, RN; Heather K.S. Laschinger, PhD, RN, FAAN, FCAHS; Wayne Weston, MD, CCFP, FCFP

Abstract

The purpose of this study was to use a cross-sectional survey design, with an integrated theoretical perspective, to examine clinical teachers’ (n = 64) and nursing students’ (n = 352) empowerment, teachers’ and students’ perceptions of teachers’ use of empowering teaching behaviors, students’ perceptions of nurses’ practice behaviors, and students’ confidence for practice in acute care settings. In this study, teachers and students were moderately empowered. Teachers reported using a high level of empowering teaching behaviors, which corresponded with students’ perceptions of teachers’ use of such behaviors. Teachers’ empowerment predicted 21% of their use of empowering teaching behaviors. Students reported nurses as using a high level of professional practice behaviors. Students felt confident for professional nursing practice. The findings have implications for practice contexts related to empowering teaching–learning environments and self-efficacy.

Abstract

The purpose of this study was to use a cross-sectional survey design, with an integrated theoretical perspective, to examine clinical teachers’ (n = 64) and nursing students’ (n = 352) empowerment, teachers’ and students’ perceptions of teachers’ use of empowering teaching behaviors, students’ perceptions of nurses’ practice behaviors, and students’ confidence for practice in acute care settings. In this study, teachers and students were moderately empowered. Teachers reported using a high level of empowering teaching behaviors, which corresponded with students’ perceptions of teachers’ use of such behaviors. Teachers’ empowerment predicted 21% of their use of empowering teaching behaviors. Students reported nurses as using a high level of professional practice behaviors. Students felt confident for professional nursing practice. The findings have implications for practice contexts related to empowering teaching–learning environments and self-efficacy.

Dr. Babenko-Mould is Assistant Professor, Dr. Iwasiw is Professor, Dr. Andrusyszyn is Professor and Director, and Dr. Laschinger is Distinguished University Professor and Arthur Labatt Family Research Chair in Human Resource Optimization, Arthur Labatt Family School of Nursing; and Dr. Weston is Professor Emeritus, Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.

This study was funded by a Social Sciences and Humanities Research Council of Canada Doctoral Fellowship Award.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Yolanda Babenko-Mould, PhD, RN, Assistant Professor, Arthur Labatt Family School of Nursing, Health Sciences Addition, Room #33, Faculty of Health Sciences, Western University, London, Ontario, Canada N6A 5C1; e-mail: ybabenko@uwo.ca.

Received: May 04, 2011
Accepted: January 04, 2012
Posted Online: March 23, 2012

Clinical teachers engage in teaching–learning partnerships with baccalaureate nursing students for the purpose of developing students’ professional knowledge, skills, and attitudes necessary for quality nursing practice. When clinical teachers role model behaviors that support active learning and create opportunities for students to develop critical thinking skills, nursing students become better prepared to practice in complex, ever-changing health care environments (Tyler, 2001). As health care settings have evolved so has the role of clinical teachers. Nurse educators, who use facilitative teaching approaches, strive to empower students to co-create new knowledge by engaging in behaviors that stimulate students’ self-awareness and self-confidence for nursing practice (Greer, 2007). By “igniting the mind,” clinical teachers can “create a learning environment that embraces challenge, support, engagement, and empowerment for all students” (Rossitto, 1997, p. 6). Nursing students and teachers are interwoven in the microcosm that exists within each health care setting. As such, clinical teachers have a role in identifying and removing barriers to students’ learning while creating opportunities for students to apply knowledge and skills that enrich patient care experiences.

It is evident that clinical teachers are key stakeholders in students’ learning processes. However, no nursing education studies have examined the influence of clinical teacher variables on nursing student variables from a nested perspective. Given the nature of the teacher–student learning relationship, it seems reasonable to conduct multilevel research to ascertain how teachers can influence students. Therefore, the purpose of this article is to present findings from a study with clinical teachers (teachers) (n = 64) and second-year baccalaureate nursing students (students) (n = 352) in acute care clinical courses to examine teacher and student predictors on students’ self-efficacy (SSE) for professional nursing practice.

Theoretical Framework

Three theoretical perspectives were integrated to guide this study: (a) the empowerment process by Conger and Kanungo (1988), (b) the theory of structural power in organizations by Kanter (1977, 1993), and (c) the self-efficacy theory by Bandura (1986). Conger and Kanungo (1988) noted that empowerment is a motivational construct, defined as enabling, which involves enhancing another’s self-efficacy. Their theory consists of five leader behavior categories: expressing confidence in others, fostering opportunities to participate in decision making, providing autonomy from bureaucratic constraints, enhancing meaningfulness of work, and facilitating goal accomplishment. We propose that a leader needs to engage in behaviors that provide sources of self-efficacy information to individuals. As a result, individuals will be more apt to engage in actions that can lead to a higher level of work effectiveness.

Kanter (1977, 1993) posited that work effectiveness is also increased through structural empowerment. Access to empowering structures (i.e., support, resources, information, and opportunity) is influenced by individuals’ power factors: connections with colleagues within and outside the organization and role flexibility and clarity. Individuals with access to empowering structures and power factors can more effectively contribute to an organization’s productivity and goals.

Bandura’s (1986) theory of self-efficacy is goal oriented in that it is based on the premise that a person’s belief in his or her own ability to perform a certain action influences whether that action is undertaken. Self-efficacy is based in social-cognitive theory. In our study, the cognitive factor (thinking) was used to focus on nursing students’ efficacy expectations or belief in themselves for carrying out specific nursing actions in acute care practice settings.

No known studies have examined teachers’ structural empowerment and use of empowering teaching behaviors while also assessing the effect of teachers’ empowerment and use of empowering teaching behaviors on SSE. An integrative examination of these perspectives of empowerment could lead to a deeper understanding of the influence of practice setting conditions on both teachers and students in acute care practice.

Related Literature

Structural Empowerment

An extensive program of research has been conducted in the nursing and non-nursing population using Kanter’s (1977, 1993) theory of structural power in organizations (structural empowerment). Structural empowerment has been linked to increased organizational commitment, increased organizational trust, decreased job strain and increased work satisfaction, increased self-efficacy, increased autonomy, decreased burnout, increased work effectiveness, and effective nurse leadership (Laschinger, 2011). Kanter’s (1977, 1993) theory is also applicable in nursing education contexts, where structural empowerment has been associated with nurse educators’ use of empowering teaching behaviors (Carlson-Catalano, 1994), an organizational climate for caring (Erwin, 1999), decreased levels of burnout and increased job satisfaction (Sarmiento, Laschinger, & Iwasiw, 2004), and clinical educators’ empowerment, decreased job tension, and increased job satisfaction (Davies, Laschinger, & Andrusyszyn, 2006). Structural empowerment has been linked to nursing students’ self-efficacy for professional nursing practice (Avolio, 1998) and psychological empowerment (Siu, Laschinger, & Vingilis, 2005).

Empowering Behaviors

Hui (1994) tested Conger and Kanungo’s (1988) empowerment process model with supervisors and their employees and established a relationship between perceived use of leader-empowering behaviors and employee performance scores. Further, clinical nurses’ perceptions of their leaders’ use of empowering behaviors was associated with clinical nurses’ higher levels of empowerment (Laschinger, Wong, McMahon, & Kaufmann, 1999) and decreased burnout (Greco, Laschinger, & Wong, 2006).

Professional Practice Behaviors

The Canadian Nurses Association (2010) stated that professional nursing practice encompasses their Code of Ethics for RNs, practice standards, and government legislation. In essence, professional practice involves teamwork, leadership characteristics, political astuteness, skills in advocacy, and management. Nursing practice competencies can be viewed as a demonstration of ethics and standards in action. For nurses to engage in professional practice to the full scope of their knowledge and abilities, such environments need to consist of the following attributes: autonomy in practice, collaborative nurse–physician relationships, and opportunities to develop and sustain therapeutic relationships with patients (Scott, Sochalski, & Aiken, 1999). Nurses’ professional practice behaviors have been positively related to caring self-efficacy and structural empowerment (Manojlovich, 2005b). Students’ professional nursing practice has been correlated to structural empowerment (Jarvie, 2004), and their professional practice behaviors have been sustained through concurrent online discussion and learning (Babenko-Mould, Andrusyszyn, & Goldenberg, 2004).

Self-Efficacy

Self-efficacy has been studied in nursing contexts with staff nurses, nurse managers, and students. Self-efficacy has been associated with empowerment, professional nursing practice behaviors, and practice competencies. Manojlovich (2005b) found that nurses’ (N = 376) self-efficacy was moderately and positively related to empowerment and professional nursing practice behaviors. She suggested that nurse leaders who provide sources of self-efficacy information, such as role modeling and verbal persuasion, may increase nurses’ confidence and improve their practice behaviors. In Jarvie’s (2004) study with nursing students (N = 27), self-efficacy for nursing practice competency was rated as high, with involvement in the nurse–patient relationship as the strongest reported level of self-efficacy. Nurse managers (N = 27) reported a high degree of self-efficacy for engaging in leadership competency behaviors and felt most self-efficacious in the roles of facilitator and mentor (Laschinger & Shamian, 1994). In addition, nurse managers’ empowerment was positively and significantly related to their managerial self-efficacy (Laschinger & Shamian, 1994). By examining the associations among the use of empowering teaching behaviors, structural empowerment, and nurses’ practice behaviors, nurse educators and clinical nurses will be in a better position to understand and develop the conditions that will support students’ learning and self-efficacy for professional nursing practice.

Hypotheses

The hypothesized model for the current study involved specification of clinical teacher and nursing student effects on nursing students’ self-efficacy for professional nursing practice. At the individual level of analysis, nursing students’ perception of their teachers’ use of empowering teaching behaviors was predicted to positively influence their experiences of structural empowerment, which in turn was predicted to have a positive influence on their self-efficacy for professional practice. At the group (teacher) level of analysis, clinical teachers’ structural empowerment and their self-reported use of empowering teaching behaviors were hypothesized to have an additional influence on SSE for professional practice. Finally, students’ perception of nurses’ practice behaviors was hypothesized to influence the student empowerment–self-efficacy relationship. A representation of the full hypothesized model is presented in Figure 1. The model, which was used to examine direct and indirect effects of nursing student level variables, is presented in Figure 2. Figure 3 represents the hypothesized moderator effect of students’ perceptions of nurses’ practice behaviors on SSE for professional nursing practice.

Figure 1. Hypothesized model of clinical teacher and nursing student effects on students' self-efficacy for professional nursing practice.

Figure 2. Model of direct and indirect effects of student-level variables on students’ self-efficacy (SSE) for professional nursing practice. Note. SETB = students’ perceptions of clinical teachers’ use of empowering teaching behaviors; SEMP = students’ structural empowerment.

Figure 3. Moderator effect of students’ perceptions of nurses’ professional practice (SPNPP). Note. SEMP = students’ structural empowerment; SSE = students’ self-efficacy.

Method

Sampling Design and Rationale

A multilevel sampling design was used with nursing students (n = 352) (level 1) nested within clinical teachers (n = 64) (level 2) for a total sample size of 416 participants (students grouped with clinical teachers). The purpose of the hypothesized model was to account for the observed variation in SSE by a set of clinical teacher and student level variables.

Participants

Participants were from seven baccalaureate nursing program sites in Ontario, Canada that offered acute care clinical courses in the second year of the 4-year programs. After ethical approval to conduct the study was obtained, the deans and directors distributed the study’s letter of information to clinical teachers facilitating second-year acute care courses. Clinical teachers interested in participating in the study contacted the researcher via e-mail. Teachers who agreed to participate received a sealed, coded study package with a postage-paid return envelope. The clinical teachers also received sealed and coded study packages for distribution to nursing students in their clinical group. Teachers were requested to distribute the student study packages to all students so that teachers would not be aware of who did or did not wish to participate in the study. In addition, clinical teachers and nursing students were asked to complete the study package in separate locations to facilitate participant anonymity. Return of the completed questionnaires by clinical teachers and nursing students by mail signified consent to participate.

Instrumentation

Four nursing student (level 1) and two clinical teacher (level 2) data collection instruments were used (Table 1). Students and teachers also each completed a demographics instrument.

Table 1. Study Instruments, Subscales, Items per Subscale, Instrument Scale, and Score Range

Analysis

Data analyses included descriptive statistics, Cronbach’s alpha reliability analyses, correlational analyses, path analysis, and hierarchical linear modeling. The main study hypothesis was tested in two stages using path analysis and hierarchical linear modeling. Path analysis was conducted to analyze a hypothesized causal model of student self-efficacy for professional practice at the individual level of analysis. The hierarchical linear modeling analysis examined the hypothesized teacher effects (level 2) on SSE for professional nursing practice in addition to student (level 1) effects. In essence, the purpose of analyzing the hypothesized model in this study was to examine SSE for professional nursing practice scores when grouped with a particular clinical teacher.

Results

Demographics

Three hundred fifty-two nursing students (93.5% women), mean age 23.51 years (SD ±5.50, range = 18 to 47 years), participated in the study. Of the 352 participants, the incidence of institutional postsecondary courses were 31.5% college, 30.7% university, and 37.8% none. Most (82.7%) nursing students noted that they wanted to practice in an acute care setting after graduation.

Sixty-four clinical teachers (95.3% women), mean age 45.87 years (SD ±9.88, range = 25 to 63 years) participated in the study. These 64 participants had an average of 6 to 10 years’ experience teaching in acute care settings, 95.3% received a university education; 51.6% and 48.4% were employed as clinical teachers full time or part time, respectively; and 25% were employed in a hospital where clinical teaching was facilitated. More than 87% of clinical teachers expressed that they wished to continue teaching in acute care practice settings after their most recent experience as a clinical teacher.

Descriptive Results

Table 2 presents the participant means and standard deviations and the study instrument overall Cronbach’s alpha values for variables at both the clinical teacher and nursing student levels.

Table 2. Means, Standard Deviations, and Study Instrument Overall Cronbach’s Alpha Values
for Study Participants

Test of Hypotheses

Path analysis techniques were used to examine the direct and indirect effects of students’ perceptions of teachers’ use of empowering teaching behaviors on SSE for professional practice through students’ structural empowerment (the mediator model). Path analysis was also used to examine the moderating effect of students’ perceptions of nurses’ professional practice behaviors on the empowerment and self-efficacy relationship.

In relation to the mediation model, there was a statistically significant direct effect of nursing students’ perceptions of clinical teachers’ use of empowering teaching behaviors (SETB) on SSE for professional practice (ß = 0.266, p < 0.001). SETB accounts for 7.1% of the variance in SSE scores (Table 3). This satisfies the first condition required for a mediation analysis according to Baron and Kenny (1986).

Table 3. Effects of Students’ Perceptions of Clinical Teachers’ Use of Empowering
Teaching Behaviors (SETB) on Students’ Self-Efficacy (SSE)

Next, there was a statistically significant direct effect of students’ structural empowerment (SEMP) on SSE for professional practice (ß = 0.402, p < 0.001). SEMP accounts for 16.1% of the variance in SSE scores (Table 4). This satisfies the second condition for mediation—that the mediator has an effect on the dependent variable (Baron & Kenny, 1986).

Table 4. Effects of Students’ Structural Empowerment (SEMP) on Students’ Self-Efficacy (SSE)

SETB has a positive indirect effect (ß = 0.176, p < 0.001 on SSE for professional nursing practice through students’ perceived SEMP. When SETB and SEMP are both included in the causal model, there is no significant direct effect of SETB to SSE (ß = 0.090, p = 0.174). In other words, when SEMP is added as a mediating variable to the model, the direct effects noted previously become nonsignificant. The variables SETB and SEMP combine to contribute 16.7% to the variance in SSE (Table 5). Therefore, the fully mediated model is supported. Figure 4 shows the final model with standardized path coefficients.

Table 5. Effects of Students’ Perceptions of Clinical Teachers’ Use of Empowering Teaching
Behaviors (SETB) and Students’ Structural Empowerment (SEMP) on Students’ Self-Efficacy (SSE)

Figure 4. Student level moderator effects model with standardized path coefficients. Note. SETB = students’ perceptions of clinical teachers’ use of empowering teaching behaviors; SEMP = students’ structural empowerment; SSE = students’ self-efficacy.

Contrary to expectations, we found that the Status and Promotion of Professional Nursing Practice Questionnaire-I does not significantly moderate the relationship between SEMP and SSE (ß = −0.419, p = 0.226) (Table 6).

Table 6. Student Level Moderator Effects

Hierarchical linear modeling was used to test the multilevel hypothesis that specified contextual teacher effects on SSE for professional practice. The final data for this analysis consisted of 293 students linked to 46 teachers (clusters). The overall sample size was smaller than planned because several teachers had two or fewer students responding.

Three models were run to test the multilevel hypothesis. First, an unconditional (null) model was examined in which no student or teacher level predictors were entered into the model. The objective of this model was to assess the magnitude of the variance in SSE attributable to group (teacher, level 2) membership. Results of this analysis indicate that 9.642% of the total variance in self-efficacy was due to across-group variability. Next, a conditional model, which included all student level (level 1) predictors but no teacher predictors (level 2), was analyzed. Results of this analysis indicated that the overall mean value for SSE was 77.74; the across group variance was statistically significant (χ2 = 66.245; p = 0.021); and the student level predictors accounted for 16.49% of level 1 variance in self-efficacy. SEMP had a statistically significant effect on self-efficacy (ß = 1.057; t = 5.115; p < 0.0001). Thus, a one-unit increase in SEMP produces a 1.057-unit increase in SSE for professional practice. Finally, the intercept model was analyzed to test whether teacher level predictors could explain across-group variability in level of self-efficacy. Variables were grand-mean centered to enhance interpretation. None of the teacher characteristics were statistically significant—that is, they did not explain variability in across-group or across-teacher differences in SSE.

Discussion

Structural Empowerment

Results of the study with both clinical teachers (n = 64) and nursing students (n = 352) further substantiate Kanter’s (1977, 1993) theory in a clinical nursing education context. Participants’ results suggest that both teachers and students felt the clinical setting was a learning environment that provided a moderate sense of “control over conditions that make their actions possible” (Laschinger, 1996, p. 28). Clinical teacher findings are consistent with previous research with college nurse educators (Erwin, 1999; Sarmiento et al., 2004) and staff nurses (Laschinger, Wong, & Greco, 2006). Nursing student structural empowerment levels are similar to those found with nursing students in the classroom setting (Siu et al., 2005). Interestingly, the level of overall structural empowerment is not substantially higher for clinical teachers and nursing students than that reported for nurse managers (Armstrong & Laschinger, 2006) and staff nurses (Cho, Laschinger, & Wong, 2006). The results support Kanter’s (1977, 1993) position that structural conditions in the work (i.e., practice) setting positively influence employees. In our study, it was clinical teachers’ and nursing students’ behavior and attitudes that were influenced.

Nurses’ Professional Practice and Empowerment

Contrary to expectations, students’ perceptions of nurses’ power to engage in professional behaviors did not positively moderate the association between SEMP and SSE for professional practice. Students certainly felt that nurses were engaging in professional behaviors. However, structural empowerment was found to be a mediator between SETB and SSE. Perhaps this can be attributed to the amount of teaching–learning time second-year students spend with clinical teachers and peers, as compared to time with staff nurses. Second-year students may be more likely to seek guidance, support, and feedback from clinical teachers and peers than from staff nurses. It is evident that students are taking notice of staff nurses’ professional behaviors, and thus staff nurses are role models for students. It is plausible that staff nurses’ practice behaviors would have a stronger impact on students in a preceptor relationship during an extended integrative practicum.

Empowering Teaching Behaviors

Our study is the first to examine both clinical teachers’ and students’ perceptions of teachers’ use of empowering teaching behaviors in an acute care setting. Clinical teachers strongly believed they were using empowering teaching behaviors with nursing students in clinical settings, and students’ responses positively corroborated teachers’ self-reported behaviors. Clinical teachers reported a low level of the behavior as providing autonomy from bureaucratic constraints. Why might this behavior be used less than the other assessed clinical teacher behaviors? Perhaps many teachers did not fully conceptualize such behaviors as being part of their role or that these behaviors could be used with students in the second year of a nursing program. Clinical teachers may not have known why this behavior was important for student learning. Also, they may not have known how to operationalize the behavior of providing autonomy from bureaucratic constraints.

Path analysis results provided further substantiation to the importance of SETB and students’ empowerment in shaping their self-efficacy for professional practice. It is reasonable to suggest that students perceived their teachers as using empowering behaviors because teachers’ actions did influence students’ learning. Empowerment mediated the relationship between SETB and students’ confidence for practice. In other words, nursing students who perceived their teachers as using empowering behaviors were more likely to feel empowered and believe themselves to be confident to practice professionally. At the student level, empowerment also had a direct effect on SSE. As such, empowerment was found to be the strongest mechanism that influenced SSE for professional practice. These findings are consistent with those of Greco et al. (2006), who found that empowerment mediated the relationship between leader-empowering behaviors and burnout, which highlighted the relevancy of leader-empowering behaviors in averting burn-out and increasing person–job fit in the practice environment. In the management literature, Tekleab, Sims, Yun, Tesluk, and Cox (2008) noted that “empowering leadership is targeted at developing the self-leadership capabilities” (p. 187).

The Canadian Nurses Association (2009) called on the profession to recognize that roles within nursing will be even more focused on leadership than in the past. Consistent with this, a primary teaching role in nursing education is to foster development of the leadership skills necessary to practice in complex health settings, the evidence associating use of empowering teaching behaviors, and structural empowerment with SSE is important for teachers and administrators to consider. The study results suggest that students feel that their teachers are involving them in decision making, supporting their confidence for practice, creating meaningful learning opportunities, and cutting through some of the red tape traditionally associated with practicing in hierarchical organizations. Consequently, students feel they have power to attain their learning goals in the practice setting. In turn, such perceptions enhance students’ confidence to practice in a way that maintains patient safety, involves patients and their families in the care process, and empowers them to competently meet patient care needs.

Self-Efficacy and Empowerment

The discourse in the literature regarding the influence of teaching on nursing students’ empowerment and confidence for practice raised the question regarding the extent of the effect of clinical teachers’ factors on nursing student outcomes. Our study sought to examine whether differences in SSE could be explained by both clinical teacher-level and student-level variables. The results of our study suggest that it is students’ own perspectives of their teachers’ empowering behaviors that mattered to their self-efficacy for professional practice. Teachers’ own perceptions of empowerment or reported use of empowering behaviors did not add significant explanatory value to SSE for professional practice.

Nursing students’ empowerment and self-efficacy for practice occurs in a social context with teachers, peers, and nurses. Almost 10% of the total variance in nursing students’ self-efficacy scores was due to clinical teacher–student group differences. These results support Kanter’s (1977, 1993) theory in that access to power factors and empowering structures leads to self-efficacy. However, teacher structural empowerment and use of empowering teaching behaviors did not account for this group-level variance. This could be due to the relatively small sample available for analysis (46 teachers clustered with 293 students) and could be considered as a study limitation. It has been suggested that with fewer groups, one may require more individuals per group (Hoffman, 1997). However, there are constraints in achieving this goal with clinical teachers and nursing students when the traditional convention is a clinical teacher-to-nursing student ratio of approximately 1:8. To replicate the study, a larger sample size would be sought from nursing programs across provinces. Because clinical teachers form but one essential part of students’ clinical learning experience, it may be difficult with a smaller level 2 sample size to determine how teacher empowerment ultimately affects students’ confidence. That being said, it is important to recall that it is clearly evident that students do in fact perceive their clinical teachers as enabling student empowerment.

Implications for Education

It is recommended that clinical coordinators, clinical teachers, and nursing program clinical liaison personnel work together to involve students with clinical nurses more fully to support students’ confidence and professional socialization. In a time of critical nursing shortages, this may be one strategy that can help students feel more visible, connected, and relevant in the practice setting. In turn, students may feel more committed to the profession as a whole, as well as to specific organizations upon graduation. Nursing faculty could participate in professional development sessions with a focus on why the use of empowering behaviors is important to develop the next generation of nurse leaders and how faculty can enact such behaviors with nursing students. These sessions could also include information about structural empowerment and how clinical teachers can advocate for and attain enhanced access to empowering structures to further develop their own, as well as students’, structural empowerment. By altering structural factors in practice settings, empowering conditions may be created, thus leading to a more empowered cadre of nurses, educators, and future nurses.

Conclusion

To the authors’ knowledge, this is the first study to have examined the effects of environment and motivation on students’ empowerment and self-efficacy for professional nursing practice from an integrated theoretical perspective. In addition, this study included clinical teacher variables in an effort to predict SSE. To date, no other study has considered both clinical teacher and nursing student contextual elements in an acute care clinical nursing education context. Students perceived their teachers to be using empowering behaviors, which was associated with their own perceptions of structural empowerment. Accordingly, both motivational and structural perceptions of empowerment were linked to students’ perceptions of their confidence for professional practice. Students also felt that nurses were engaged in employing professional practice behaviors. Similar to students, clinical teachers felt both structurally empowered and perceived themselves to be using empowering behaviors in the teaching–learning context with students. In light of the evidence that associates empowerment with organizational commitment (Laschinger, Finegan, & Wilk, 2009), job satisfaction (Kuo, Yin, & Li, 2008), a climate of patient safety (Armstrong, Laschinger, & Wong, 2009), and decreased work stress (Li, Chen, & Kuo, 2008), leaders in both academic and practice settings could collaborate to create healthy practice environments where clinical teaching and learning is supported and enhanced.

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Study Instruments, Subscales, Items per Subscale, Instrument Scale, and Score Range

Instrument Overall Cronbach’s Alpha Subscale and Items per Subscale Instrument Scale Score Range
CWEQ-II-ED (students) 0.78 Formal power: 2 Informal power: 4 Information: 6 Opportunity: 6 Resources: 5 Support: 7 (validity check— global empowerment: 2) Five point scale: 1 = none 3 = some 5 = a lot 6–30 Higher score relates to students’ higher perceived structural empowerment.
SPPNPQ-I (students) 0.94 Nurses’ behaviors necessitated due to bureaucratic structure and its constraints: 7 Nurses’ behaviors hindered by bureaucratic structure and its constraints: 7 Five point scale: 1 = strongly disbelieve 5 = strongly believe 7–35 Higher score reflects students’ perceptions of nurses’ use of professional practice behaviors.
SEPNPQ (students) 0.86 Helping : 6 Teaching–coaching: 6 Patient monitoring: 6 Managing rapidly changing situations: 6 Administering and monitoring therapeutic interventions: 6 Monitoring and ensuring quality health practices: 6 Organizational and work role competencies: 6 0 to 100 point scale: 0 = not confident at all 100 = very confident Overall score can range from 0 to 100. Higher score reflects higher level of nursing students’ perceived self-efficacy.
ETBQ-S 0.89 Enhancing meaningfulness of work: 6 Encouraging participation in decision making: 5 Expressing confidence in high performance: 5 Facilitating goal accomplishment: 6 Providing autonomy from bureaucratic constraints: 5 Seven point scale: 1 = strongly disagree 7 = strongly agree 1–7 Higher score indicates students’ perception of clinical teachers as using higher levels of empowering teaching behaviors.
CWEQ-II-CT 0.73 Formal power: 9 Informal power: 3 Information: 3 Opportunity : 3 Resources : 3 Support: 3 (validity check—global empowerment: 2) Five point scale: 1 = none 3 = some 5 = a lot 6–30 Higher score relates to clinical teachers’ higher perceived structural empowerment.
ETBQ-CT 0.85 Enhancing meaningfulness of work: 6 Encouraging participation in decision making: 5 Expressing confidence in high performance: 5 Facilitating goal accomplishment: 6 Providing autonomy from bureaucratic constraints: 5 Seven point scale: 1 = strongly disagree 7 = strongly agree 1–7 Higher score indicates clinical teachers’ perception of themselves as using a higher level of empowering teaching behaviors.

Means, Standard Deviations, and Study Instrument Overall Cronbach’s Alpha Values for Study Participants

Variable Mean SD Cronbach’s Alpha
Level 1 (students) (n = 352)


  Structural empowerment 21.50 3.33 0.78
  Perceptions of teachers’ use of empowering behaviors 5.19 1.19 0.89
  Perceptions of nurses’ practice behaviors 3.73 0.74 0.94
  Self-efficacy for professional practice 77.47 10.20 0.86
  Age 23.51 5.50
  Students’ desire to practice in acute care after graduation 0.82 0.37
Level 2 (clinical teacher) (n = 64)


  Perceived use of empowering teaching behavior 5.52 1.13 0.85
  Structural empowerment 18.73 3.28 0.73
  Years of clinical teaching experience 0.47 0.50
  Age 45.87 9.88

Effects of Students’ Perceptions of Clinical Teachers’ Use of Empowering Teaching Behaviors (SETB) on Students’ Self-Efficacy (SSE)

Path Estimate Standard Error Est. S.E. pValue Standardized Estimate R2
SSE on SETB 2.265 0.517 4.378 < 0.001 0.266 0.071

Effects of Students’ Structural Empowerment (SEMP) on Students’ Self-Efficacy (SSE)

Path Estimate Standard Error Est. S.E. pValue Standardized Estimate R2
SSE on SEMP 1.229 0.181 6.789 < 0.001 0.402 0.161

Effects of Students’ Perceptions of Clinical Teachers’ Use of Empowering Teaching Behaviors (SETB) and Students’ Structural Empowerment (SEMP) on Students’ Self-Efficacy (SSE)

Path Estimate Standard Error Est. S.E. pValue Standardized Estimate
SSE on SETB




  Total effect 2.265 0.517 4.378 0.000 0.266
  Direct effect 0.769 0.566 1.358 0.174 0.090
  Indirect effect 1.497 0.398 3.763 < 0.001 0.176
SSE on SEMP 1.093 0.231 4.725 0.000 0.357
SEMP on SETB 1.369 0.232 5.895 0.000 0.492
R2




  SSE: 0.167




  SEMP: 0.242




Student Level Moderator Effects

Path Estimate Standard Error Est. S.E. pValue Standardized Estimate
SSE on




  SEMP 1.722 0.664 2.594 0.009 0.563
  SPPNPQ-I 5.071 3.399 1.492 0.136 0.371
  INTER −0.185 0.153 −1.211 0.226 −0.419
Authors

Dr. Babenko-Mould is Assistant Professor, Dr. Iwasiw is Professor, Dr. Andrusyszyn is Professor and Director, and Dr. Laschinger is Distinguished University Professor and Arthur Labatt Family Research Chair in Human Resource Optimization, Arthur Labatt Family School of Nursing; and Dr. Weston is Professor Emeritus, Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.

This study was funded by a Social Sciences and Humanities Research Council of Canada Doctoral Fellowship Award.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Yolanda Babenko-Mould, PhD, RN, Assistant Professor, Arthur Labatt Family School of Nursing, Health Sciences Addition, Room #33, Faculty of Health Sciences, Western University, London, Ontario, Canada N6A 5C1; e-mail: ybabenko@uwo.ca

10.3928/01484834-20120323-06

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