VOL: 97, ISSUE: 22, PAGE NO: 40
Mark Faulkner, PhD, MSc, BA, RGN, CertTHEd, is lecturer in gerontology and continuing care, School of Nursing and Midwifery, University of Sheffield
The term ‘empowerment’ has become increasingly popular in nursing, where it is used in a variety of contexts and given an assortment of meanings (Gibson, 1991).
In an attempt to synthesise these meanings, this article will consider the issue of patient empowerment, exploring how it is expressed in health care policy and examining the theoretical foundations that underpin it.
Empowerment, as it relates to health care, implies that patient independence may be optimised by helping patients to assert control over their lives (Gibson, 1991). This principle is highlighted in a number of professional and governmental guidelines where it is seen as a vital ingredient in the provision of quality health services.
For example, the Code of Professional Conduct (UKCC, 1992) emphasises that it is the responsibility of nurses to foster patient independence by recognising and respecting their involvement in the planning and delivery of care. Your Guide to the NHS (Department of Health, 2001) broadens the application of empowering care to encompass all health care professions. It suggests not only that services will be shaped around the needs and preferences of each patient but also that access to information on treatment and service performance will be open to all.
Despite this emphasis on empowering care, numerous studies show that people in hospitals and institutions are often exposed to circumstances that seem to contradict this principle (Mountain and Bowie, 1995; Draper, 1996). This ‘disempowering’ care ranges from mildly negative interactions, such as invading a patient’s privacy or disturbing patients while they are resting, to more severe examples, such as scolding, neglect and physical restraint.
The Dignity on the Ward campaign run by The Observer newspaper prompted the government to commission an independent inquiry into the acute care of older people in general hospital wards. The subsequent report, subtitled ‘Not Because They Are Old’ (Health Advisory Service, 1998), noted a number of deficiencies, such as delays in admission, shortages of equipment and supplies, a lack of staff and disempowering care. Examples included several instances where patient dignity was compromised or professionals were disrespectful to patients.
In a partial response to this, the government drafted Your Guide to the NHS (DoH, 2001). Elements of this paper had already been presented in both The NHS Plan (DoH, 2000) and a preliminary statement by Dyke (1998).
These documents reflect the priorities of patients, as outlined in the King’s Fund report (Ferrell et al, 1998), and emphasise the importance of empowering care. Examples include the provision of comprehensive information to patients about their condition, treatment and the choices available to them.
The government’s drive to raise standards of care, particularly those relating to patient empowerment, is not restricted to the NHS and extends to the independent sector. The consultation document Fit for the Future? (DoH, 1999) epitomises the government’s commitment to establishing required standards for residential and nursing homes in recognition of the somewhat sketchy regulations set out in the Registered Homes Act (DoH, 1984).
These standards refer to a wide variety of topics. However, there is one that is particularly relevant to empowerment. It refers to the ‘rights of individual residents’ and has subtopics on the subjects of privacy, dignity, fulfilment, respect and choice. For example, the subtopic on choice suggests: ‘Residents must be given choice in relation to social activities; food; routines of daily living; personal and social relationships; religious observance; and the handling of their deaths’ (DoH, 1999).
This empowering standard is clearly appropriate for older people in long-term care, enabling them to assert control over their lives and maintain a degree of independence.
Against this backdrop, it is not only easy to see the relevance of the concepts of empowerment and disempowerment to health care, but also to notice two important related links. First, that disempowering care leads to increased dependence and, second, that empowering care optimises independence.
While much of health care literature espouses these links, most examples are anecdotal or opinion-based. Nevertheless, some experimental literature exists. For instance, with reference to the link between disempowering care and dependence, research by Avorn and Langer (1982) shows that older patients develop an ‘induced disability’ when exposed to uncontrollability, specifically over-assistance with a psychomotor task.
Conversely, with regard to the link between empowering care and independence, several studies show that increasing older patients’ exposure to controllable circumstances results in increased levels of activity and ‘zest for life’ (Langer and Rodin, 1976; Mercer and Kane, 1979).
But what are the psychological processes, if any, that govern these links?
From the perspective of disempowerment, the answer to this question potentially lies in the substantive psychological theory of ‘learned helplessness’ (Seligman, 1975), which states that when people experience uncontrollable events, they form an expectation that future events will be uncontrollable as well.
This expectation subsequently leads to three deficits:
- A motivational deficit, described as a lowered probability of initiating voluntary instrumental responses;
- A cognitive deficit, described as a difficulty in learning that responses produce outcomes when they do;
- An emotional deficit considered to be a consequence of learning that outcomes are independent of responding. These deficits may affect performance in a myriad of alternative tasks, not simply in the task in which they were induced.
Translating this theory into the language of health care, it could be argued that the disempowering actions of hospital staff, which prevent older people from asserting control over their lives, inadvertently expose them to circumstances consistent with the development of learned helplessness.
Moreover, the effects of learned helplessness may be viewed in terms of dependence, with patients being unable to perform tasks without supervision, direction or active personal assistance as a result of ‘motivational’ and ‘cognitive’ effects.
The psychological theory of learned mastery could be considered relevant here (Peterson et al, 1993). It is almost the complete opposite of learned helplessness: the argument goes that when people are exposed to controllable events they develop an expectation that future events will also be controllable. Subsequently, this expectation leads to an increased incentive motivation and an enhanced awareness of controllable circumstances when they exist.
When this opposing theory is translated into the language of health care, it could be argued that the empowering actions of hospital staff expose patients to circumstances consistent with the development of learned mastery. In turn, the effects of learned mastery should enable patients to perform tasks without supervision, direction or active personal assistance, effectively optimising their independence within the limits of an individual’s mental and/or physical capabilities.
Research I have undertaken supports the link between learned helplessness and dependence, and learned mastery and independence. It shows that over-assisting older people in hospital with the activity of feeding - a disempowering interaction - results in increased levels of passivity, akin to a learned helplessness-induced dependence.
Moreover, this dependence was shown to negatively affect patient performance in an alternative psychomotor task. Therefore, by disempowering patients in a single task their performance in many other tasks may decline. However, when the same patients were verbally informed that they would be in control of feeding without interference, they showed an increased duration of instrumental responding, akin to the development of learned mastery-induced independence.
This increasing independence was also shown to generalise to an alternative psychomotor task, only this time leading to performance gains. Thus empowering patients in undertaking a single task provides them with the potential to make gains in independence in many other tasks.
Although this article strongly advocates empowering care, empowerment is not a panacea for all types of dependence. Even when used appropriately, patients may not necessarily display signs of increased independence - this relies very much on a patient’s frame of mind (McWilliam et al, 1994). It is recommended that carers evaluate a patient’s goals, aspirations and sense of purpose within the wider life context as a means of tailoring empowering strategies to meet individual needs (McWilliam et al, 1994).
It should also be noted that in the case of some patients, the use of empowering strategies may be more detrimental than beneficial. For example, it is argued that with increasing age, greater control over activities, circumstances or health may lead to the complications of stress, worry and self-blame (Rodin, 1986).
Whether appropriate or not, some patients’ desire to relinquish personal control is a choice that must be respected. Consequently, it may be necessary for practitioners to assess the extent to which older people want autonomy in their lives, and if they do whether this could result in undue anxiety or stress.