What is empowerment?

There is no consensus definition of the concept of empowerment, but WHO’s definition appears to be an appropriate point of departure: “Empowerment is the process of increasing the capacity of individuals or groups to make choices and to transform those choices into desired actions and outcomes,” (WHO 2006: 17).

In health care, empowerment is usually viewed as a social process or strategy for achieving control over factors and decisions affecting one’s health (Gibson 1991), and of enhancing patients’ autonomy and capacity to make informed decisions (Kapp 1985).

Empowerment is a relational concept (Gibson 1991; Tveiten 2007), where one part helps or facilitate the ‘empowering’ of the other part. Further, an empowerment process entails a transfer of control and power from the nurse to the patient through dialogue, for instance through strategies such as motivation training, guidance, coaching, teaching, and shared-decision making. Hence, a central principle in empowerment is to acknowledge the patient as the expert on his own situation (Tveiten 2007).

Despite these intuitively positive associations, empowerment in practice presents some ethical questions that have yet to be thoroughly explored. For instance, little work has been done on whether the use of empowerment strategies in nurse-patient relationships is compatible with accepted standards for autonomous action. In what follows, I will sketch out some of the questions that crop up when considering empowerment within the context of nursing care.

Empowerment and autonomy

The relation between empowerment, autonomy, and consent in the nurse-patient relationship is interesting for several reasons. For instance, very often, being in need of nursing care means being in a very vulnerable position. Further, an increasing number of patients in need of nursing care have dementia or other forms of cognitive impairments, something that challenges their capacity of consent in the first place, as well as their capacity to participate in empowerment processes aimed at enhancing their consent. In such situations, the exercise of autonomy is dependent on the existence of caring and trusting relationships (Lôhmus 2015: 11).

To be consistent with the emphasis on acknowledging the patient as an expert on his own situation, we should respect that some people do not want to take control over their own lives. We should also respect that some patients do not want to participate in empowerment processes aimed at enhancing their consent, and we should respect the fully informed patient who still doesn’t want to make a decision, but instead wishes to be dependent on health professionals (Kapp 1985).

Empowerment and capacity to consent

According to WHO’s definition of empowerment, the outcome of a successful empowerment process is an individual who possesses increased capacity to make choices as well as increased ability to transform these choices into desirable actions and outcomes. Now, whereas philosophical literature is dealing with informed consent and decisional capacity at a conceptual level, it is not clear what increased decisional capacity amounts to in practice. Does it, for instance, imply that a patient who lacks decisional capacity in a certain situation, may gain such capacity through an empowerment process?

One further problem then relates to the fact that it will be unclear whether the outcome is a feeling of being empowered or actually being empowered to make own decisions (Kieffer 1983), and how these distinctions relate to autonomy and valid consent. This point is important since the choice made, according to WHO’s definition, is to be transformed into a desirable action and outcome. An additional question then is: desirable according to whom? Health care authorities, nurses, and the patient in question may have different opinions concerning what a desirable outcome of a situation should be. An empowerment process may, therefore, result in a choice and action that may conflict with what is professionally desirable and recommendable.

A third difficulty relates to Kapp’s (1985) point that decision-making power must be accepted voluntarily. This would imply that neither empowerment nor autonomy can be forced upon someone. But then we must ask if empowerment could be considered an intervention that presupposes voluntary participation in the first place. The central problem here is the extent to which participation in an empowerment process that is intended to increase capacity to consent, presupposes autonomy and consent. If that is the case, empowerment appears to be an awkward bundle to carry:

If empowerment is compatible with an acceptable standard of autonomy, would this imply that becoming autonomous presupposes already being autonomous? If it is not the case, however, that participation in an empowerment process requires being autonomous, would this imply that a patient legitimately can be forced to participate in an empowerment process aimed at enhancing this patient’s autonomy? Or does empowerment represent a form of manipulation or coercion?

Empowerment and paternalism

This leads to my hypothesis that empowerment may have paternalistic undertones. For instance, adequate information is essential to empowerment (Kapp 1989), and so it is for a patient to fully possess understanding of the action and its consequences, which is one of the standard criteria of autonomous action. Besides, the idea that concern for patients’ own experiences, comprehension of needs, values, and desires constitutes a hallmark of empowerment, and is also of fundamental importance in respecting a patient’s autonomy.

But it is unclear how much weight the patient’s own values and desires should have in cases where these conflict with the best-up-to-date research findings, and how the different kinds of knowledge should be balanced in an empowerment process. For example, evidence-based-practice has become highly influential in nursing care, and, according to evidence-based practice, health care should be based on the best up-to-date research findings (Gupta 2014).

Central questions then are: if too much emphasis is placed on the patient’s own values and desires in an empowerment process at the expense of professional knowledge, do we run the risk of diminished professional responsibility? Or is the asymmetry in power in favour of the nurse reinforced by the considerable emphasis such factors as the best-up-to-date research findings?

In either case, there is a need for further discussions on the compatibility between the use of empowerment strategies in nurse-patient relationships to enhance patients’ use of knowledge to make informed decisions and accepted standards for autonomous action. Hopefully, the use of empowerment strategies could be considered a justified trust building intervention aimed at preventing coercive actions or (more) paternalistic interventions.

References

Gibson, C. 1991. “A concept analysis of empowerment”. Journal of Advanced Nursing. 16 (3). 354–361.

Gupta, M. 2014. Is evidence-based psychiatry ethical?. Oxford University Press.

Kapp, M. 1989. “Medical Empowerment of the Elderly”. The Hastings Center Report. 19 (4). 5–7.

Kieffer, C. 1983. “Citizen empowerment: a developmental perspective”. Prevention in Human Services. 3 (2–3). 9–36.

Lôhmus, K. 2015. Caring Autonomy. Cambridge University Press.

Tveiten, S. 2007. Den vet best hvor skoen trykker: om veiledning i empowermentprosessen. Fagbokforlaget.

WHO. 2006. “What is the evidence of effectiveness of empowerment to improve health?” WHO.

 

Marita Nordhaug is Associate Professor at Oslo Metropolitan University and currently part of a research group on empowerment.

Photo: Sonja Balci