Review
Patient empowerment in theory and practice: Polysemy or cacophony?

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Abstract

Objective

This paper examines how the term “empowerment” has been used in relation to the care and education of patients with chronic conditions over the past decade.

Methods

Fifty-five articles were analysed, using a qualitative method of thematic analysis.

Results

Empowerment is more often defined according to some of its anticipated outcomes rather than to its very nature. However, because they do not respect the principle of self-determination, most anticipated outcomes and most evaluation criteria are not specific to empowerment. Concerning the process of empowerment, our analysis shows that (i) the educational objectives of an empowerment-based approach are not disease-specific, but concern the reinforcement or development of general psychosocial skills instead; (ii) empowering methods of education are necessarily patient-centred and based on experiential learning; and (iii) the provider–patient relationship needs to be continuous and self-involving on both sides.

Conclusion

Our analysis did not allow for the unfolding of a well-articulated theory on patient empowerment but revealed a number of guiding principles and values.

Practice implications

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.

Introduction

People who are told that they will have to live with a chronic disease often have to face major changes in their everyday life. Not only do they have to learn a lot about the disease and its treatment, they are also often told to integrate a number of new lifestyle or treatment-related behaviours into their everyday life. These behaviours may be difficult to adopt on a long-term basis, as they often conflict with existing behaviours, priorities or projects. Thus, the need for change occurs not only at a behavioural level, but also at a psychosocial level. Indeed, “being chronically ill is a total experience influencing all facets of life” [1]. As patients become aware of the life changes they will have to consent to in order to adjust to their disease, they may experience a distressing feeling of powerlessness. Powerlessness was defined by Freire (1973, cited by [2]) as occurring when an individual assumes the role of an “object” acted upon by the environment, rather than a “subject” acting in and on the environment. Powerlessness has been acknowledged as a determinant of ill health [3]. Conversely, empowerment may be considered as a health enhancing process [4], [5].

In the field of health-care, empowerment has been acknowledged as an alternative to compliance in order to guide the provider–patient relationship. Whereas in the more traditional compliance-oriented approach to health-care, patients are seen as the recipients of medical decisions and prescriptions, the empowerment-oriented approach views patients as being responsible for their choices and the consequences of their choices. However, there are many interpretations of the term “empowerment”, based on different understandings of the concept [6].

The idea of empowerment is rooted in the “social action” ideology of the 1960s and the “self-help” perspectives of the 1970s [2]. It puts an emphasis on the rights and abilities rather than deficits and needs of the individuals and communities [7]. In the 1990s, the Ottawa Charter for Health Promotion [8] has made empowerment a key issue in the theory of health-promotion, which focuses on positive health enhancement rather than only ill-health prevention, mainly through the improvement of social conditions [9]. In the field of community psychology or human resources development, empowerment has been conceptualised as being at the crossroads of individual and community or organisational development. In this perspective, individuals contribute to a common goal within a collective process of social change [3], [5], [9], [10]. In other words, one central feature of community or organisational empowerment is to make use of individual competence to collectively initiate changes.

In the field of health-care, an attempt to clarify the concept was done by Gibson [11]. Her analysis shows that a great number of characteristics are associated to the concept, making it difficult to think of empowerment consistently and in operational terms, in order to allow for its implementation in health-care settings. While some authors feel comfortable with the idea that empowerment may take on a different form in different people and within different contexts (e.g. [7]), other authors (e.g. [2]) have argued that in order to establish the utility of the term “empowerment” for theory as well as for practice, a precise and functional definition was needed.

This paper examines how the term “empowerment” has been used in relation to the care and education of patients with chronic conditions over the past decade. Based on the results of a literature review, we seek to establish whether it has acquired a consistent meaning and whether some guidelines on how to put it into practice may be issued.

Section snippets

Methods

Three international databases – Medline, Current Contents, and PsycInfo – were searched over a 10-year period (1995–2005), using two keywords: “patient education” and “empowerment”. The results of this search for each of the databases were 145, 59 and 18 articles, respectively. The abstracts of all articles were checked so as to select the articles according to five inclusion criteria:

  • -

    the article should concern adult patients with a somatic chronic disease (articles relating to psychiatric

Results

Our selection of articles included 27 research articles [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38] and 28 theoretical papers [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49], [50], [51], [52], [53], [54], [55], [56], [57], [58], [59], [60], [61], [62], [63], [64], [65], [66]. As we generally expect a concept to be more systematically and precisely defined in

Discussion

The key features of an empowerment-based approach are ideology driven and concern choice and responsibility on the one hand, and skills-development so as to become more competent in relating to self and others, and dealing with one's disease, life and environment on the other hand. These features clearly posit empowerment within a humanistic approach of human motivation and development, which postulates that there is an intrinsic tendency in humans toward self-growth or “self-actualisation”

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