ClinicalSelf-empowermentinhealthpromotion: a
realistictarget?NiciMackintoshTherehave heenmanycalls fornursesto
adopt aself-empowermentmodel
forhealthpromotionpracticeratherthancontinuingto workfromthe
medicalmodel. Continuingwithour series onhealthpromotion,this
article examinesfeaturesof
theself-empowermentapproachandquestionswhetherits goals
areachievahle.TJLh(Nici Mackintoshis SeniorClinicalNurseat
SandwellHealthcareNHSTrust,WestMidlands4lhheterm'healthpromotion'is'verydifficulttopindownfordescriptivepur-poses'(Beattie,1991).Inthisarticle,it
isaccepted that health promotion includes:'...both health education
and all attemptsto produce environmental and
legislativechangeconducivetogoodhealth'(Dennis et al,1982).While
healthpromotioninvolves the
alter-nativeandcomplementaryprocessesofsocialengineeringandhealtheducation,thelatterisaboutfacilitatinghealthchoices:'Healtheducationisconcernedwithraisingindividuals'competenceandknowledgeabouthealthandillness,aboutthebody
anditsfunctions,aboutpreventionandcoping;withraisingcompetenceandknowledgetousethehealth-care
system and to understand itsfunctions;andwithraisingawarenessabout
social, political and
environmentalfactorsthatinfluencehealth*(Baric,
1985).StrategiesforhealtheducationHealtheducationtakesdifferentapproaches.Inanefforttoexaminethepracticalimplicationsandgoalsforeachstrategy,manyauthorshaveattemptedtodeviseclassificationsfortheseapproaches(e.g.Tones.1981,1986;Beattie,1982,1991).Fiveclassificationsforsuchapproaches
can be identified{Table 1).Researchstudies(Johnston,1988;
Latteretal,1992;
Mackintosh,1993)havecon-firmedthatthemajorityofnursespersistwiththebehaviouralchangeapproach.Gottand
O'Brien(1990) place responsibil-ity forthis
situationonindividualistic
ide-ologiesandlimitedhealthpromotionprogrammesandpoliciesforhealthinnursingwhichemphasiseframeworksofindividualisticactionat
the expense of col-lective nursing
philosophies.Criticsofthebehaviouralchangemodelpointoutthatitassumesthatlaypeoplebelieve
the 'experts' know best. The
modelimposesmedicalvaluesontheindividualand may also impose
feelingsof guilt if
theclientchoosesnortofollowtheregime.Moreover,intermsofaviolationofrespectfortheindividual'sautonomy,thereareethicalobjectionstoitsassump-tionthatprofessionalshavetherighttodecidewhatconstitutes'healthybehaviour'.Boththebehaviouralchangeandeduca-tionalapproachesembracetheexistentialbelief
that;'Peoplearebornfreeandcreatethemselvesbymeansoftheirdecisionsand
choices' (Jacob,1994).Individualsare perceivedas freeto choosea
courseofactionandarethereforecon-sideredresponsiblefortheirhealth.Thisindividualisticconceptofhealthhasbeenstronglycriticizedasitfailstotakeade-quateaccountofthesocialandeconomicdeterminantsofill-healthandhealth-relatedbehaviouroutsideanindividual'scontrol.The
socialactionapproachviews
humannaturefromthedeterministperspective.Deterministsbelievethata
person'sfree-dom is limitedby biological,
psychologicalandsocialforces. Thesecause factorssuchas race,
gender, socialclass andgenetics
tobecomethedeterminantsofhealth.Thisstrategynotonlyaddresses
thefundamen-talsocialissuesunderlyingdisadvantageandill-health,butalsocanberegardedascoercive
forit seeks to perpetuatea
partic-ularpoliticalviewofsociety(Tones,1986).Furthermore,itseemsnaivetoplacetotalresponsibilityforhealthon
the state.Whereas the governmenthas a dutyto
cre-atefacilitiesforhealth,itisstilluptotheindividualtoactuponinformationin
aBritish Journalof Nursing,1995. Vol 4, No 211273Self-empowermentin
healthpromotion: a realistictarget?TableI. Strategic approaches for
health educationBehaviour change (preventiveor traditional
approach)Focus: the individualEducational approachSocial action,
radical, socialchange approachSelf-empowerment,humanistic
approachCommunitydevelopmentapproachGoal: to persuade the
individual to adopt a particularlifestyle/adhere tomedical advice
to prevent/limitdisease and reduce
mortality/morbidityratesRationale: curativemedicine cannot cope
withcurrentrate of
disease.Preventionbetter/cheaperthancureEvaluation: measured on
whetheror not the individual adopts a particularlifestyle or
changes his/herbehaviourExample: advising/persuading the individual
to give up smokingFocus: the individualGoal: to help the
individualdevelop his/herknowledge and skills
andexplorehis/herattitudes, so that he/she can make an informed
choice abouthis/her healthRationale: education is about
rationalityand freedom of choiceEvaluation: measured on the
facilitation of decision-making, irrespective ofthe nature of the
decision actually madeExample; presenting the individual with the
facts about smoking and leavingtheindividual to make a choiceFocus:
the environment at societal levelGoal: to make healthy choices the
easy choices by changing the physicaland social environment so that
individuals are enabled to adopthealthybehaviour. Also aim to raise
individuals' awareness and involvement in healthissues in orderto
stimulate the demand for social changeRationale: the root of health
problemslies in social, economicand politicalfactorsEvaluation:
measured on the implementation of critical consciousness-raising,
and/orsocial, political or environmentalchange conducive to
healthExample: campaigning for smoke-free areas, lobbying
parliament for anadvertising ban on tobaccoFocus: the
individualGoal: to facilitatedecision-making by modifying the
individual'sself-concept and enhancing self-esteemRationale: by
developing motivation, setf-confidence and skills, theindividual is
in a betterposition to identifyhis/her own health needs and
takeaction to meet themEvaluation: measured on the acquisition of
life skills and decision-makingskillsExample: enabling the
individual to identify why he/she smokes, helping theindividual to
develop the confidence and skillsneeded to make a choice
andimplement a health planFocus: a groupGoal: to help a group
worktogether, find its commoninterests andfight its
particularhealth causeRationale: it is betterto workfrom the
group's valuable experiencesrather than to workfrom a
professionallydefined agendaEvaluation: measured by successful
public awareness raising of the group'sconcernsand the
implementation of health action for the benefit of the
groupExample: identifying a need for a self-help group,
facilitating the group, actingas resource and supporterfor the
group1274Brlti5h Journal of Nursing, 1995, Vol 4. No
21Self-empowermentin health promotion: a realistictarget?^Within
thehospital setting itis oftenmuchharder toempower
theindividualbecause of thenature of theinstitution itself.However^
on asmaller scale, thenature of personalinteractionsbetween
nurseand patientcanplay an
importantpart.'waythathe/shethinksbest.Asocialactionstrategymay
failtoprovidetheindividualwiththe motivationto internal-izethe
valuesitpromotesortopromoteautonomousself-care.Anapproachinvolvingthe
pursuitofself-empowermentfacilitatesinformedchoiceswhichare so
hardto achieve withtheeducationalapproach.Aself-empow-erment
strategy aims
to:PromotebeliefsandattitudesfavourabletodeferringimmediaterewardformoresubstantialfuturebenefitIncreaseinternalcontrolandself-esteemanddevelopsocialskills,e.g.
assertiveness (Tones,1981)Thus,the onusis on the individual,
butbecausethe
self-empowermentstrategyaimstohelplearnersbecomemoreself-assertive,tbe
individualis able
todevelopanotionofbeingincontrol.Aself-empoweredpersonis
betterableto resistpressurestosmoke(Tones,1986)
andhasmoreunderstandingandcontroloversocial, economic and political
forces.Thecommunitydevelopmentapproachshares many featuresof
theself-empower-mentapproach,but it is on a larger scale.Whereasthe
self-empowermentapproachislimitedtodevelopingtheindividual'sabilitytodealwithsocialinjustices,thecommunitydevelopmentapproachallowscertaingroupstoworktogethertofightfortheir
health needs.*If nursingis to take healthpromotionseriouslyit
mustbe activelyconcernedwiththe empowermentof clients andpatients'
(Tones,1993).Recognitionof the criticismslevelled
atthebehaviouralchangemodel,togetherwithrecentinterestinholisticand
client-centrednursing,has resultedin a
changeoffocusinhealthpromotioninnursingtowards the theory
ofself-empowerment.Theory ofself-empowermentThere are
fourfactorswhichTones
(1993)considerscentraltotheconceptofempoweredaction for the
individual:1. Theenvironmentalcircumstanceswhichmay
eitherfacilitatethe exerciseof controlor, conversely, presenta
bar-rier to freeaction2.The extent to which individuals
actuallypossesscompetenciesandskillswhichenablethemto
controlsomeaspects oftheirlives, and perhapsovercomeenvi-ronmental
barriers3.The extentto wbichindividualsbelievethemselves to be in
control4.Various emotionalstates or traits
whichtypicallyaccompanydifferentbeliefsaboutcontrol
suchasfeelingsofhelplessnessand
depression,orfeelingsofself-worth.Oneof the criticismsagainstthe
educa-tionalapproachisthatthemereunder-standing of a healthissue is
not enough toprecipitatehealthaction. The provision
ofinformationneedstobe accompaniedbyprocessesof beliefand the
clarificationofvalues, followedby some practicein deci-sion-making
usuallyin a simulated set-ting.For self-empowermenttooccur,
adevelopmentalprogrammeisrequired,aimedatcertainaspectsofpersonalgrowth.Two
importantpersonalitychar-acteristicscentraltothisprocessare
self-esteem and locus of control (Tones, 1986).Self-empowermentin
practiceManynursesconcernedwithcommunitydevelopmentare
involvedinempoweringboth individuals and groups. The agenda
isfrequentlyset byindividualswithinthecommunityratherthanby the
profession-als, and the role of the nurse is not that
ofanexpert,but of a facilitatorand
partner.Forexample,theschoolnursemayrespondtoteenagers'requeststorun
aworkshopon copingwiththe problem ofpeer pressure to
experimentwithdrugs, orapracticenursemay set upaself-helpgroupto
helpindividualsdealwithstress.Igoe(1993)andWalker(1993)providefurtherexamplesofcommunitysettingswiththe
potentialforself-empowermentstrategies.Withinthehospitalsettingitisoftenmuchhardertoempowertheindividualbecauseofthenatureoftheinstitutionitself.However,on
a smallerscale, thenatureofpersonalinteractionsbetweennurseand
patientcan playanimportantpart. By respectingthe
individual'swishesandallowingthepatienttherighttochoose,the
likelihoodofdisempoweringthemdividualis minimized.Believing
thatonehas
somekindofcontroloverone'slifeisbeneficialinmanyways(Tones,1993).
However,merelyhavingthe beliefthatone is in control is not
generallysuffi-cientfortheempowermentprocesstobegin;theindividualmustalsobe
pro-videdwiththecompetenciesneededtoachieve his/her
goals.Wilson-Barnett(1993)notedthatenabling people to maximize
theirindivid-British Journal o( Nursing,1995. Vol 4, No
211275Self-empowermentinhealthpromotion: a
realistictarget?Howmanynurses are in apositionto
giveadequatequalitytimeandprivacy,in a
suitableerivironmentytoenable thepersonaldevelopmentof
apatieritfNursesofteii take on tberole of Jianiednurse for anumber
ofpatientsand areunable, due tolack of contacttime,to buildupthe
deptb ofrelationshipnecessary todeveloppatients'life-skills
andpotentialformanagingtbeirownhealth.ualpotentialshouldbetheaimofmany.\j;encies(statutoryandvoluntary)and'healthprofessionalsmaybeinaspecialsituationloinfluencethis'.Butarenursesina
positiontofacilitatepatients'personalj^rowth? In order to examine
this
question,thelocationoftheempowermentprocesswithmthecontextofthecounselhngrela-tionship
must be established.Person-centredcounsellingItis possibletodrawa
parallelconclusionbetweencertaincharacteristicsoftheper-son-centredcounselling
relationshipof
theclientandcounsellorandtherelationshipestablishedina
self-empowermentstrat-egy.Person-centredcounsellingplaceshighvalueontheindividual'sexperiencesandtheimportanceoftheindividual'ssubjectiveperceptionsofreality.Itchal-lenges
each personto acceptresponsibilityforhis/herownlife,andtotrustthe
irmerresourcesavailabletoallthosewhoarepreparedtodevelopself-awarenessandself-acceptance.Thenotionsofself-empowermentandperson-centredcounsellingbothfitintothecategoryofa
'helpingrelationship*, asdefinedby Rogers (1967):'A helping
relationship is one in which atleast one of thepartieshas the
intent
ofpromotingthegrowth,development,maturity,improvedfutictioning,andimproved
coping with life of the
other.'Theyalsoemphasizetheimportanceofunleashingthepowerthatlieswithintheindividualratherthanrelyingontheauthorityof
the expert.Table 2. People involved
inhealthpromotionTown-plannersAgriculturalistsIndustrialistsandbusinessmenPoliticiansThoseinvolvedwithcommunicationandmassmediaEnvironmentalhealthworkersDirectorsof
transportservicesEducationalistsandsocialworkersMedicalandheatth-careprofessionalsSource:
Tones
(1966)Itthereforefollowsthatmanyoftheconditionsnecessaryforthedevelopmentofatherapeuticrelationshipbetweencounsellorandclientmay
also be
requiredtofosteragrowth-conduciveclimatebetweenpatientandhealth-promoter.However,oncloserexamination,theful-filmentoftheseconditionsislikelytobeseenasproblematicwithincertainfieldsof
nursing.First, howmanynursesare in a positionto:Be
genuine?Offerunconditionalpositiveregard
andtotalacceptance?Feelandcommunicatea deepempathicunderstanding
towards the patient?Yet the counsellormust demonstrate
thesequalitiesinordertofacilitatethepersonalgrowthof the client
(Rogers, 1967).Second, the client voluntarilychoosestoforma
relationshipwiththecounsellor.Thepatient,ontheotherhand,isoftenforcedtoformsomekindofrelationshipwith
the nurse. There is still the element
ofchoiceastowhatformthisrelationshipshouldtake, buthe/she maymay
not wishtotakeresponsibilityforhis/herown
health.Howmanynursesareina positiontogive
adequatequalitytimeandprivacy, ina
suitableenvironment,toenabletheper-sonaldevelopmentofapatient?Nursesoftentake
on the role of namednurse for anumberofpatientsandare unable,
duetolack ofcontacttime, tobuildupthe
depthofrelationshipnecessarytodeveloppatients'life-skillsandpotentialforman-aging
their own healthThus, we need to question
thefeasibilityofsettingself-empowermentasa
goalfornursingpractice.Itisquestionablewhetherthemajorityofnursesareinasufficientlycredibleandempoweredposi-tionthemselves
tobe able to facilitate
self-discoveryinothers.Howmanynurseshaveaccesstosupportnetworksandopportunitiesforguidancefromqualifiedexpertsto
dealwithemotionallythreaten-mg situations?Thereis an
additionalproblemforthosenursesworkingwithinthehospitalstruc-ture.Themanagementofhealthandwel-fareissues
has
traditionallybeenplacedinthehandsofexperts,locatedwithinlarge,centralizedbureaucracies.Ina
systemthatcallsfordominancebyprofessionals,it
isdifficulttoachieveegalitarianworkingrelationships.A
callforactivelyparticipa-tiverolesforpatientschallengestheexist-1276BritishJournalofNursing.1995.
Vol 4, No 21Self-empowermentin healthpromotion: a
realistictarget?ingpower/controlbase(Kcyzcr,1988).Thereistheaddeddangerthat,inanattempttoadoptafacilitativeapproach,activitieswhicharc,inreality,manipula-tive
anddefinedbythenurse'sagenda canbe labelledas
participative.Similarly, many of the measures for
eval-uationofhealthpromotionsuccesswithinbothcommunityandhospitalset-tings
are still definedby the
behaviouralchangeapproach.Itishardfornursestowork within a model
ofself-empowermentwhentheirworkisoftenevaluatedbycomplianceratesandevidenceof'positive'changesinlifestyle(Mackintosh,1996).Thereisalsoa
dangerthatnurseswillfocusonthosepatientswhoarereceptivetoandateasewiththenotionoftakingcontrolforthemselves.Thesepatientsarelikelytobeinthehighersocialclasses.
Ineffect,thisactuallyperpetuatessocialinequalityandmaintainsthestatus
quo:'...thegreatestbeneficiariesbeing
thosewhoarealreadywellabletocaterfortheirownhealthneeds, andwho
havethe power and social influenceto changethingsfurthertotheirown
advantage'(Campbell, 1993).The definitionof
self-empowermentalsoinvolves the facilitationof some exercise
ofcontrolovertheenvironment.Itis ques-tionable how many nurses are
in a positionto do this.KEYPOINTSThere are
threeindividualistichealth educationapproaches:behaviour change;
educational; and self-empowerment.Traditionally, the focus in
health education in nursing hasbeen one of behavioural change.More
recently, many authors have advocated a move towardsa
self-empowermentapproach for nursing.Due to the constraints of the
working environment andnurses' lack of skills, it is often
unrealisticto expect themajority of nurses to be in a position to
empower andfaciiitate the personal growth of a patient.It is
important to acknowledge that nurses are in an importantposition as
providers of information, not as indoctrinators oradvisors, but as
carers.Nurses have a duty to acknowledge the social structural
facetof health.SettingnewtargetsItis importantnottolose sightofthe.
factthatthelistofthoseinvolvedinhealthpromotionisextensive{Table
2).
Onceitisacknowledgedthathealthprofessionalsactuallyplayarelativelymarginalroleinhealth
promotionwithin the wider
contextofpublichealth,itmaybeeasierfornursestore-cvaluatetheaimsoftheirpractice.
After
all:'Healthpromotionmustuseawidevarietyofcomplementarystrategies'(World
Health Organization, 1984).All
healtheducationstrategiesshouldberecognizedashavingtheirowndegreeofimportance,
sincehealthcanonlybe pro-motedin societywhenan
amalgamofdif-ferentapproaches are applied.Therefore,the aims
ofhealthpromotionpractice fornurses should
be:Tostriveforunconditionalacceptanceof the health values of
individualsToshowconsiderationoftheenviron-mentalandsocialfactorsaffectingindividualsTo
offerhealth informationwhich
shouldnottaketheformofindoctrination,advice, or
persuasion.Nursesneedtobeaware thatit is almostimpossibleto
giveinformationthat is totally devoid of valuejudgments. Thus,
nurses needto developtheircommunicationskillsandexaminetheir
position as providers of
information.Healthpromotionpracticefornursesshould thereforetake
the formof:ValuingindividualsandtheirhealthbeliefsShowing
sensitivitytotheenvironmen-tal,socialandeconomicfactorsaffect-ing
the health status of individualsProviding
healthinformationConstantlyevaluatingandreviewingtheaccuracyofavailablehealthinfor-mationRaisingindividuals'awarenessofthesocial,economicandenvironmentaldeterminantsof
healthInformingindividualsoftheirrights,and how to access other
servicesInvolvingindividualsindecision-mak-ing
wheneverpossibleOfferingsupporttoindividualsbymobilizingappropriateresourcesandliaising
with appropriateprofessionalsRespectingindividuals'rights
tochoosetheir own courses of action
forhealthUnitingwithothernursestoensurethatprofessionalbodieslobbyforgoodpublic
health poUcies.BritishJournalof Nursing.1995, Vol 4, No
211277Self-enipowerinentin health promotion: a realistic
target?ConclusionWhereasthosenurseswho are in a
posi-tiontofacilitatepersonalgrowthinpatientsshouldbe encouragedto
do so, itis importantnot to excludethose who
arenot.Therefore,allnursesshouldbeencouragedto assesstheirrolesas
carers,andtoreviewtheirrelationshipswithpatientsfromtheperspectiveoftheirpotentiallypowerfulpositionsas
healthprofessionalsand information-givers.Inthis way, nurses can
use approaches whichtakenote of
socialstructurefactorswhilefocusingon individuals'needsand
theirpersonal resources.Baric L (1985) The meaning of words:
healthpromo-t i on. ;InstHealthEdHc2ii\):367-72Beattie A
(1982)ChangmgCodes of
Health.SeminarNotes.InstituteofEducation,UniversityofLondonBeattieA(1991)Knowledgeand
controlinhealthpromotion:a testcaseforsocialpolicyand
socialtheory.In: Gabe J,CalnanM, BuryM.
eds.TheSociologyoftheHealthService.Routledge,London:162-202Dennis
J, DraperP, HollandS, ShipsterP, Speller
VandSuntcrI(1982)HealthPromotionintheReorganisedNHS.UnitforStudyofHealthPolicy,LondonCampbellA
(1993)The
ethicsofhealtheducation.In:Wilson-BarnettJ,Macleod-ClarkJ,eds.ResearchinHealthPromotionandNursing.MacmillanPress,
Hampshire: 2-8GottM, O'BrienM (1990) The role of the nurse
inhealthpromotion.HealthPromotionInt 5(2):3 7 3Igoe
J(1993)Healthierchildrenthroughempower-ment.In: Wilson-BarnettJ,
Macleod-ClarkJ,eds.ResearchinHealthPromotionandNursing.Macmillan
Press, Hampshire:145-53JacobF
(1994)Ethicsinhealthpromotion:freedomor determinism?BrJ Nurs3(6):
299-302JohnstonI(1988)Astudyofthepromotionofhealthylifestylesbyhospitalbasedstaff.UnpublishedMScthesis,UniversityofBirminghamKeyZL-rD(1988)Challengingroleboundaries:
con-ceptualframeworksfor understandingthe conflictarisingfromthe
implementationot t henursingprocessin practice.In: White R, ed.
Political IssuesinNursing:Past, Present and Future.Vol 3.
WileyandSons, Chichester,95-119LatterS, Macleod-Clark J,
Wiison-Barnett J, Mabin J(1992)Healtheducationin nursing:
perceptions ofpractice in acute settings./-4(/i;M