Patient Empowerment in Nursing

The concept of empowerment has being analysed and defined in different areas and most human activities. This concept of empowerment can be found in education, social work, psychology and nursing. This concept has being used depending on the writer and what he or she wants to write about. It is therefore more often defined according to some of its expected results rather than to its original state.

This paper will focus on patient empowerment and present a concept of analysis of its characteristics, attributes and antecedents in the nursing field, whiles critically analysing its significance, application and implication within the nursing practice.

The writer believes that the goal of empowerment and therefore patient empowerment is well-being. For Van Gedder 2002, “within the health, empowerment is seen as a key determinant of health”.

The writer also believes that patient empowerment is about respecting and valuing the patients’ preferences in improving or increasing health services. Secondly, patients that are empowered would be able to make decisions regarding their treatment with respect to the nurses that are treating them.

Empowerment has different definitions and meanings in different frameworks and situations. It can therefore be in many disciplines: social, political, economic, psychology, education and organisations among others.

Empowerment is defined as a multi-dimensional social process that helps people to gain control over their lives. It is as process that fosters power in people for use in their own lives, their communities and in their society, by acting on issues they define as important.(Nanette Page & Cheryl E. Czuba 1999).

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For Rodwell(1996 p. 309) “Empowerment is a process of enabling people to choose to take control over and make decisions about their lives. It is process which values all those involved”. Sally Kendall in her book, titled, “Health and Empowerment”,1998, continued by affirming that, Rodwell wrote from the nursing perspective and is more supportive of an empowering approach where notions of helping partnerships and mutual decision-making are more prominent than critical consciousness-raising or radical action.

In reference to the work of Zimmerman & Rappaport(1988) they also defined empowerment as a build that connects personal capabilities and power, positive behaviour and natural healing systems to issues of social change and social policy.

According to the free online dictionary, empowerment is the giving or delegation of power or authority (authorization), the given of an ability (enablement or permission) and in government politics and diplomacy, a policy of providing special opportunities in employment, training etc. for the disadvantaged. In affirming this, Sanjay T. Menon (2002) wrote that, “Empowerment reflects the process by which the less powerful are given the opportunity to gain more power and control over specific life experiences”. Menon defined this in the sociological perspective.

Lovemore N. and Katie L. (2002), in their work “Empowerment in Nursing”, referred to the Brazilian educator Paulo Freire(1994), who emphasise that empowerment is a process by which people can learn to take control of their lives. He further viewed empowerment as both a process and an outcome. However whiles empowerment is an outcome, it is not a dichotomous variable, in that one is or is not empowered. Instead, empowerment is a continuous variable, more similar to a direction than allocation.(Robert M. & Martha M. 2009)

According to Rappaport(1984), empowerment is the mechanism by which people, organisations and communities gain mastery over their lives. Rappaport defined empowerment as a process. This definition captures the idea that empowerment is something which occurs within the individual or community and is not simple transfer of power from one to another. (Sally Kendall 1998, p. 2-3). In the same sense (Gibson,1991, p.359) also emphasised that, empowerment is a social process of recognising, promoting and enhancing peoples’ abilities to meet their own needs, solve their own problems and mobilise the necessary resources in order to feel in control of their own lives’.

Studying Gibson’s definition of empowerment, Sally Kendall(1998 p. 3) explained that Gibson’s analysis is presented in the nursing context, and whilst the emphasis is on enabling and facilitating from within, one does not feel a strong sense of the nurses’ role in the political and structural domain of empowerment from Gibson’s work.

What then is patient empowerment? In today’s health services, patient empowerment has being the focus of health policies of the government and the department of health and therefore is growing in popularity.

Nursing literature holds many definitions of patient empowerment. According to Funnel, et al (1991), patient empowerment in the health care context means to promote autonomous self-regulation so that the individual’s potential for health and wellness is maximized. Also Craddock and Skinner(2000) define empowered patient as one who will experience a specific level of consultation with his or her healthcare provider.

Furthermore, the patient empowerment concept, which is a recently growing in health, emphasizes that, people must bring about changes in their social and community situations and in the environment that has an impact on their lives, not only in their personal behaviour in order to be truly healthy.

Patient empowerment is a process intended to help independent performance. Patient empowerment is the freedom to choose where and when one has treatment and implies that patients should retain autonomy and responsibility for decision-making during their treatment. (Malin and Teasdale,1991). It is stressed here that empowerment of the individual in a way maximizes the patient independence and minimize their dependence. Patient empowerment therefore means the independence of patient, information exchange, being aware of patient’s needs and choices, retaining their autonomy, respecting their decisions among others. In other context, patient empowerment is a process where individuals are helped to have control over factors which affect their health. Van Gedder(2002), then remarks that “the ultimate goal of empowerment and therefore patient empowerment is well-being. Within health empowerment is seen as a key determinant of health”.

Finally, David Samoocha, emphasised that, patient empowerment refers to the enhanced ability of patients to actively understand and influence their own health status. It focuses on control in individuals’ experience of health, disease and illness as well as the roles of health care organisations, communities and the broader health care system. (David Samoocha, www.jmr.org, Assessed on 10th Nov. 2010)

The antecedents of patient empowerment are trust, respect, commitment, education, health messages, inspiration and contribution and staff empowerment.

Firstly, respect as an antecedent of patient empowerment is very important because a person must always have respect and attentiveness for individuals believes and values.(Tones 1991) The relationship in respect is not one-sided where one part of it is viewed as inferior or incompetent and the other side is viewed as superior and more competent.(Gibson 1991).

Patients, to reach conclusions about the risks to their health, access information from a variety of sources including the media, the internet, friends and family (Glenn Laverack, 2009). For Funnel, et al(1991), patient empowerment begins with information and education and includes seeking out information about one’s own illness or condition, and actively participating in treatment decisions. Empowerment requires the individual to take care of one’s self and make choices about care from among the options identified by the doctor. Information is power and therefore informed patients are better equipped to take the numerous advantages and opportunities. They are able to access services, exercise their rights, negotiate effectively and can effectively hold people accountable.

With the work of Lovemore N. and Katie L. Dunn (2002), they referred to the work of Paulo Freire(1994), who outlined empowerment through education. His philosophy of empowerment through education is explained well in his work the Pedagogy of the oppressed. In this work he emphasizes the processes by which people can learn to take control of their lives. Empowerment is a process when the purpose of an educational intervention is to increase one’s ability to think critically and act autonomously.

However, Lovemore N. and Katie L(2002), stressed that health empowerment requires more than information and education. As a process health empowerment requires a positive nurse-patient interaction where there is mutual trust and reciprocal understanding of healthcare needs. Gibson(1991) refers to the work of Hurty(1984), Kirp & Epstein(1989), that trust is very necessary condition in the empowerment process. The nurse-patient relationship is based on trust. Patients must believe in the honesty and reliability of nurses.

Another important antecedent of patient empowerment is commitment. Empowerment cannot be successful if both individuals are not committed to the process.

Application of the concept to the healthcare setting is complex and foreign due to paternalism and traditionalism and therefore an important antecedent of patient empowerment is staff empowerment, wherein empowerment can be understood and the concept transferred and operationalised. (Tyna Williams, 2002). As the nurses are empowered, they will recognise their knowledge and experiences about the distribution of power.

Gibson (1991) points out that, from the nursing perspective, these antecedents to and necessary conditions of empowerment involve a shift in thinking in relation to the role of the nurse as a sensitizer to self-awareness and self-growth as well as a resource. If nurses are to subscribe to an empowerment model, they need to legitimate the beliefs that people are equal partners in the health care team.

In the literature review attempts have been made to identify the characteristics of the concept of empowerment. According to Kiefer(1984), empowerment is associated with such characteristics as mutual support, support systems, self-efficacy, self-esteem, competence and self-sufficiency. In a recent work by Tengland (2008), suggested, ability (physical, financial, mental and legal), control over life or health, self-efficacy, self-esteem, autonomy and freedom and concluded that there are two plausible commentary uses, one as a goal and one as a process or approach.

Since optimal health demands empowerment, and therefore all patients gain power and freedom from empowerment. Empowerment is seen as a process towards patient autonomy and therefore everyone still breathing has the right to self-determination. In other words patient autonomy refers to the right of patients/clients making as much of the health care decisions as they desire.

Respect for patient autonomy is seen as an important element of patient-centred and ethical care. There is therefore the need for nurses to surrender the control and involve patients in making care decisions and exert control over their health needs. In his analysis, Gibson (1991) compared the traditional biomedical model of care with an empirical model of care. The empowerment model of care illustrates the kind of shift in thinking required to allow patient empowerment to take place. Patient autonomy is therefore seen as a rational rather than independent and patients must be motivated to act autonomously through shared information and mutual collaboration in decision making.

The suggestion that personal efficacy, self-sufficiency and self-esteem are associated with empowerment and therefore patient empowerment are also postulated by Tones(1991).The notion of self-efficacy is the conviction that empowered patients can successfully change their behaviour to reach their goals. Not only does self-efficacy reduce disease symptoms it can also help bring about self-directed behavioural changes. The process of empowerment lives at the heart of healing and hence patients are empowered when they have the knowledge, skills, attitude and self-awareness to influence their own behaviour. According to Sally Kendall(1988) self-efficacy theory is concerned with an individual’s perception of personal efficacy. Perceptions of efficacy determine whether or not individuals will first attempt an action or behaviour and secondly the extent to which they will persevere in overcoming obstacles and finally be successful in the challenge. A research conducted by Gecas1989 indicated that high self-efficacy (power) has beneficial and therefore therapeutic consequences for individuals and low self-efficacy (powerlessness) has negative and maladaptive consequences.

Tones(1991) draws the relationship between control and empowerment in that patients who feel they have control of their situations are likely to exhibit behaviour that will better enable them to cope with potential threatening situations than those who feel that chance or other non-controllable factors determine whether their behaviour is successful. Beliefs about control are considered to be valuable and contribute to personal efficacy and thus to patient empowerment.

Kiefer(1984) stressed that, empowerment focuses more on solutions than on problems. It addresses people’s strengths, rights and abilities rather than deficits and needs. Empowered patients with competence and ability have good interpersonal and listening skills and their practice demonstrates that they value and respect the knowledge, experience and aspirations of those involved. They will start, develop and maintain relationships with nurses and work effectively with them using non-formal contact informal support, and informal and formal learning and development opportunities.

On mutual support, Zimmerman (1995) suggests that empowerment must include processes and structures that enhance the empowered with and provide them with the mutual support necessary to affect their change.

Finally, empowerment is a transactional concept because the process involves a relationship with others. Although empowerment involves an individual demand, it is nurtured by the effects of collaborative efforts.(Kiefer 1984). Katz(1984) also points out that there are intrinsic and extrinsic connections between individual and community empowerment. He viewed empowerment within a synergistic paradigm. Where patients and nurses are interrelated, there is a sharing of power and mutual collaboration is encouraged.

On the attributes of empowerment, Rodwell(1996) examined it in his literature and suggested that it is a collaborative process between the patient and the nurses characterized by open communication and common goal setting, the availability of alternatives of decisions and the acceptance of accountability, reciprocal decision making in mobilizing the resources and the opportunities that are available and rightly using the power. It is also an interdependent participation between the patients and the nurses, dynamic listening that will help each party to have experience and learn from others and personal knowledge or cognitive acquisitions gained from each other. (Zimmerman 1995). The attribute of patient empowerment postulated by Katz 1984, is that, in an attempt to empower individuals, the person requires some attributes such as loyalty, instinctive thoughts, flexibility, respect of diversity, supportive, courage, readiness to negotiation and understanding.

Finally, for the best outcome of patient empowerment, nurses should provide support as they seek to meet important goals and manage their health problems. Funnel & Anderson(2004) suggest that, this can be accomplished by nurses listening to the patient identified fears and concerns, ascertaining their beliefs, thoughts and feelings that might hinder or support their efforts and asking what patients need to obtain from their interactions with health care providers.(Heather K. Spence Laschinger (2010)p.1-14)

The implications of patient empowerment within the nursing practice will now be examined. Nurses have a therapeutic interaction with their patients for the outcomes of nursing care. That is, nurses work with patients/clients to ensure that they have the necessary information, support and resources to promote health and well-being. (Spence L. et al (2010)p.1-14)

According to Jones and Meleis (1993) empowerment may serve as a potential health enhancing process. Empowered nurses are better able to empower their patients which have a positive impact on patients’ feelings and empowerment and better health outcomes.

In an article in the Journal of nursing by Heather K. Spence Laschinger (2010), it is mentioned that, several nursing scholars (Leino-Kilpi et al. 1998,1999, McWilliam et al. 2001, Allen & Warner 2002, Ford-Gilboe 2002) describe the nurse-patient relationship as an empowering process in which the nurse and patient collaborate to create optimal patient health.

As already stated, an antecedent to patient empowerment is staff empowerment. The empowered nurses are better able to empower their patients which will have a positive impact on patients’ feelings of empowerment and better health outcomes. The empowered nurses will know from experience about the transfer and sharing of power and the impact of the foundation of power. This will enhance the nurse-patient relationship by patient empowerment. The empowered patients’ undertaking will go beyond the patients still in the subordinate role. On the other hand, for those nurses who have not experienced empowerment, the nurse-patient relationship will seem distorted with no clear line of responsibility. These nurses are most likely to feel threatened, at risk, and uncomfortable with patient empowerment and the patients here will feel worse than before.(Tyna Williams, 2002)

Are patients empowered? Some nurses are mentally set and uses authoritarian leadership style and most empowered patients are rather characterised as difficult patients for example. According to Lovemore N. & Katie L.(2002) refers to the work of Kuokkannen & Leino Lippi(2002), concluded that empowerment in nursing continues to be compromised by its hierarchical mental set, which predominantly uses authoritarian leadership style. Empowered patients likely to ask questions and want to be directly involved in the discussions and choices that directly affect their lives , are often , instead of being encouraged to maximize their sense of empowerment are often become labelled as difficult patient(e.g. the unpopular patient) and may be alienated.(Lovemore N. & Katie L.(2002).

Also some nurses, rather than sharing power with patients dictate care delivery in a professional way. According to Lovemore N. & Katie L.(2002), the continued use of the term “patient” by nurses is seen as militating against patient empowerment.

According to Peter S. & George M(2004), patients asked to make decisions about treatment options are the paradigmatic way of being empowered. Increasingly, patients are given information in the belief that this will enable informed choices. However, detailed studies of the ways that patients with cancer use information have proved inconsistent with this belief. Patients value being given information as a way of building relationships with clinicians and maintaining hope but not as a basis for decision-making. In an interview to study of women making treatment decisions about ovarian cancer, whereas most felt that they had made a decision, they felt that they had no choice. To the patients, treatment decision-making simply meant coming to terms with the disease and acquiescing to the recommendations of the doctor, who they thought knew the right treatment.(Peter S. & George M,2004)

There are some patients/clients who may not want to be empowered. Some people, who have lived in powerless circumstances, may feel that they do not have the right or do not possess the motivation to empower themselves. Likewise, mentally ill or people with an addiction may not have the ability to organise and mobilise themselves towards empowerment.

Furthermore, nursing places patient empowerment as central concern to nurses. But it is noted that it has not been easy to achieve a genuine patient empowerment, due to the fact that in order to empower patients, nurses must be prepared to share power. The sharing of power, according to, Heather K.S(2010), between nurses and patients need a realignment of the traditional medical model of nursing care in which nurses as experts direct patient care process and the patient being seen as a daily task or the patient occupying the sick role.

To conclude, patient empowerment is a process that helps patients gain control over their own lives. The goals and outcomes of patient empowerment should neither be predefined by the health-care professionals, nor restricted to some disease and treatment-related outcomes, but should be discussed and negotiated with every patient, according to his/her own particular situation and life priorities.

Involving patients in the decisions of their health has become a key element of recent health care policies in England. Patient empowerment is therefore intended to enable patients/clients to be members of the care team and seen as experts of their illness and nurses and other health care professionals as experts on the medical conditions. Thus, both, sharing the know-how could achieve the anticipated stage for managing illness.

Maintaining or achieving best possible health outcomes of patients demand that they access information from all sources. Nurses can play a vital role in assisting patients/clients to recognize such sources of empowerment within their own health situations.

Finally there is the need for nurses to recognize their role as a couch or co-worker in the health process and to recognize and support patients/clients rights and responsibilities to make self-care choices and be the ones to make the final decisions.