Empowerment: what about theevidence?

T. Chas. Skinner*, Sue CradockABSTRACTThe health care system has been very successful in meeting the ®rst set of challenges in diabetes care. As a consequenceof this success a new set of challenge, low levels of self-care, poor control and unresolved emotional problems, hasemerged to challenge the health care professional. Patient empowerment has been cited as an approach to address theseissues. However much of this literature does little to de®ne empowerment, and tends to rely on philosophical ratherthan empirical argument. This paper de®nes empowerment as involving at least 5 key features; acceptance, affect,autonomy, alliance and active participation. These concepts are de®ned, and the pertinent diabetes literature isreviewed. Empirical studies demonstrate a clear association between aspects of empowerment and self-care behaviour.Although intervention studies have tested some aspects of the empowerment model, there is as yet no publishedempirical study that has tested the empowerment model in its entirety. Until such data emerges the empowermentmodel, although promising, can only be argued for on philosophical grounds. Copyright # 2000 John Wiley & Sons,Ltd.

Practical Diabetes Int 2000: 17(3); 91±95

KEY WORDSempowerment; autonomy; self-care; satisfaction; communication; behaviour change

Empowerment: thebeginning of an evidencebasePatient empowerment has become abuzz word among diabetes healthcare professionals (HCPs). Evenrecent desktop guides to the care ofpatients with diabetes in DiabeticMedicine called for patients to beempowered to manage their dia-

betes.1,2 Although medicine hasbeen successful in meeting the ®rstset of challenges in diabetes care,studies demonstrating the low levelsof self-care, poor control and unre-solved emotional problems continueto mount.3±8 These new challengesled researchers to reconsider thetraditional model of health care andpropose the empowerment model.9

However, not all of the discussionhas been supportive of this newmodel of diabetes care. A theory byitself is insuf®cient to warrant awholesale change to the process ofcare delivery. Therefore, this articleaims to brie¯y review a selection ofthe empirical diabetes literature. It isby no means a systematic review ofthe empowerment literature. Rather,it is a selection of work thatsupports the empowerment model,and highlights the emerging evidencefor this approach to diabetes care. Ifthere are published empirical studiesthat do not support this approach,we have not been able to locate

them, and would appreciate know-ledge of any that exist.

Before considering the streams ofevidence that are being drawn togetherto support an `empowerment'approach to diabetes care, it is essen-tial that there is a common under-standing of what this approach entails.Rather than provide a cold de®nitionof empowerment, that does not cap-ture the dynamic, humanistic essenceof the approach, some of the corefeatures of an `empowering consulta-tion' will be discussed. In addition,clarifying the process enables eachfeature to be evaluated, and allowsconsideration of which elements areessential for an effective empoweringencounter. The authors feel there areat least ®ve key features to anempowering consultation: acceptance,affect, autonomy, alliance and activeparticipation.

Acceptance, or unconditional posi-tive regard, refers to the respect thatthe HCP must have for the personwith diabetes. This means refraining

T. Chas. Skinner, Senior Research Of®cer,

Research and Development Unit, University

Hospital Lewisham, Lewisham High Street,

London SE13 6LH, UK

Sue Cradock, Diabetes Nurse Specialist,

Portsmouth Diabetes Centre, Queen

Alexandra Hospital, Cosham, Portsmouth

PO6 3LY, UK

*Correspondence to:

T. Chas. Skinner

Research and Development Unit, University

Hospital Lewisham, Lewisham High Street,

London SE13 6LH, UK

Submitted: 24 September 1999

Accepted: 15 December 1999

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from judging, condemning or in anyway conveying any negative assess-ment of the person with diabetes. Nomatter what their degree of metaboliccontrol, lifestyle, appearance or atti-tudes, the individual must be valuedfor who they are and what they wantto become, including acceptance ofthe goals the individual may want toset. An individual may not want toimprove their control, or change theirlifestyle. They may just want to feelless guilty about not controlling theirdiabetes or following lifestyle advice.These decisions must be accepted andvalued. The individual may not wantto change what the HCP wants themto change. That is their decision. Ifthe HCP helps the individual changewhat they want to change, theyimprove the probability they willcome back when they are ready tomake changes to their lifestyle.Furthermore, if the HCP tries to talksomeone into attempting to changesomething they had no desire tochange when they walked into theconsultation, they are unlikely tofollow through with the behaviourchange when they walk out of theconsultation.

Affect refers to the emotional con-tent of an empowering consultation.When exploring the problem theindividual wishes to address, it isessential to explore the emotions theindividual associates with the pro-blem. It is essential to ask what theyfeel, and how strong their feelings arewhen working through the process ofproblem solving and change. Explor-ing the individual's answers to thesequestions drives a couple of importantprocesses. First, exploration of theiremotions reinforces and enhances theindividual's motivation to addressthe problem and change. It allows theHCP the opportunity to support theindividual to improve their lifestyle, ifthat is what they want, and help themimprove their emotional well-being,an equally important goal of diabetescare. Discussing these issues may alsohelp the HCP to identify individualswith emotional problems, such asdepression, which is largely unrecog-

nised and untreated in diabetescare.7,8

Autonomy relates to the involvementand participation of the person withdiabetes in the consultation. Theindividual with diabetes should beresponsible for much of the contentof the consultation, with the HCPresponding to the individual's needs.The individual is responsible forchoosing the content of the consulta-tion and making all non-diagnosticdecisions. It is the HCP's job toensure that decisions are based onaccurate, evidence based information,and not their own personal subjectiveopinion. The HCP can diagnose aproblem, inform the patient about thenature of diabetes and its complica-tions, and relate treatment optionsand probable or possible outcomes tothe individual. However, the decisionlies with the patient, even if it is atodds with what the HCP believes. It isthe individual's diabetes: they are theperson who has to walk out of thedoor and enact the treatment, livewith diabetes every day, wake up withit every morning and go to bed with itevery night. The individual withdiabetes also has to accept the con-sequences of their decisions. We cannever fully comprehend the rationalefor a fellow human being's choices. Allwe can do is trust that each individualis making the best possible informeddecision they can, in the context oftheir perception of their life. There-fore, it should be acknowledged thatthe individual with diabetes should bethe person with most, if not all, of thepower in the consultation.

From the description of an empow-ering consultation given here, itshould be clear that HCPs should beworking in alliance with the indivi-dual, trying to help them make aninformed choice about their diabetes,lifestyle and treatment. This is doneby providing them with the informa-tion they need, in an environmentthat enables them to use it. Theperson with diabetes is not workingfor the HCP. There is no point to aconsultation if the individual believesthey are there to make the HCP

`happy', for example, by ®lling intheir blood glucose record books thenight before a consultation. HCPsshould strive to be allies of theperson with diabetes, providing themwith the equipment and resources theycannot obtain for themselves andplanning co-ordinated campaignsagainst the `same enemy', but theHCP and patient must remain inde-pendent, as each member of thealliance has different goals, needs anddesires. It is natural that the HCP andindividual with diabetes will havedifferent goals, needs and desires.Differing HCP and patient goalsshould not be seen as a problem, butshould be recognised as a potentialcause of con¯ict if they are notconsidered by both parties.

The last key feature refers to theactive participation of everyone in theconsultation. Although the patient ismaking most of the decisions, and isresponsible for the focus of discussion,this does not mean the HCP shouldbe a passive participant in the encoun-ter. The HCP must ®rst of all be avery active listener. Really listeningand hearing what someone says is nota passive process. HCPs need toensure they hear everything that issaid. How often do people start tolisten, hear something that they thinkis the crux of the matter and then leapin with the solution? How often dopeople actually wait until the otherperson has ®nished talking, beforedeciding how to respond? Even thenit is frequently the ®rst thing that washeard that is responded to, not theentirety of the communication. Peopleoften process thoughts and workthrough them as they speak. Oftenpeople end up somewhere completelydifferent from where they started, andfrom where they thought they weregoing. Everyone has a tendency tomisinterpret what people say to ®tinto our understanding or perceptionof a situation. We need to listen toeverything an individual says, andcheck that we understand them cor-rectly. As an old wise man once said`the less I spoke, the more I listened,the more I listened the more I heard,

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the more I heard the less I spoke, theless I spoke the more I said'. TheHCP is also active in the questionsthey ask. Consultations should not bean undirected, purposeless discussionabout diabetes. An empowering con-sultation involves distinct phases and aprocess to help the individual identifythe issue they want to address, whatthey want to change about it, howthey feel about it and options forchange, establishes a commitment tochange and guides an exploration ofthe barriers to change.10 The role ofHCP is to actively guide the indivi-dual through the process, attending tothe person (maintaining eye contact,attentive body language, actively lis-tening), actively striving to understandtheir perceptions, thoughts and feel-ings, but gently guiding the individualfrom one stage to the next.

The individual with diabetes has todecide what they want to change, andre¯ect on their feelings about theissue. It is their responsibility to askfor information and work to identifypotential solutions to their problem. Itis the person with diabetes who has todecide which solution they want towork with. It is the person withdiabetes who, after committing them-selves to action, has to enact thatchange in the real world, which isfrequently the hardest part of thewhole process.

Finally, it should be rememberedthat empowerment is concerned withworking alongside the individual,without making any assumptionsabout what they may or may notwant. Some people will not want todiscuss their emotions or treatmentoptions, or to work so hard in aconsultation. If this is the case, thenthe HCP should respond appropri-ately. This must be clearly what theindividual wants, before the HCPremoves this autonomy from thepatient. It should be rememberedthat it is not only the HCP who isindoctrinated into the traditionalpatient-professional roles. Our culturehas taught us that medicine will cureall our ills. All we need is a diagnosisfollowed by the appropriate treatment.

Even with a chronic illness we expectHCPs to provide us with a treatmentthat will control and manage oursymptoms. We are taught to expectsimple solutions to our medical pro-blems. Therefore, individuals withdiabetes may take time to adjust to anew way of working, but this need toadjust does not mean they do notwant to work within a new frame-work.

Is there any evidence that thisapproach will achieve anything? Evi-dence for the empowerment approachis emerging in the literature, fromboth the descriptive and interventionresearch.

Kyngas et al.11 interviewed adoles-cents about their perceptions of theHCPs responsible for their care,speci®cally their physician and nurse.The adolescents' descriptions of theircarers' behaviour were grouped intocategories. Two of these categories,`motivating' and `routine', werecommon to both nurses and physi-cians. Characteristics of the motivat-ing category included the following:the HCP asks, listens and takes noticeof the adolescent's opinion; decisionsconcerning care are made together;action of professionals is in¯uenced byadolescents. The HCPs in the routinecategory were described as: actingaccording to their goals, asking thesame questions every visit, withanswers being ignored. For physiciansthe other two categories were `author-itarian' and `negligent'. For nursesthe other category was `behavingaccording to physician's instruction'.What is important to note is thatthose adolescents whose HCPs weredescribed as motivating, closely relatedto the description of empowerment,were more likely to have `goodcompliance' and have better metaboliccontrol.

Street and colleagues12 recorded theconsultations of nurses with patientswith type 2 diabetes attending a threeand a half day diabetes educationcourse. The recorded consultationswere coded by assistants blind to thepurpose of the research. After control-ling for baseline HbA1, follow-up

HbA1, taken two to three monthsafter the consultations, was predictedby features of the nurse-patient inter-actions. Speci®cally, after interactingwith nurses who were more control-ling and directive in their commu-nication, patients experienced poorermetabolic control.

Another important descriptivestudy was recently published by Wil-liams and colleagues.13 They con-ducted a prospective study of 128adults with diabetes. Their data indi-cate that when the health care climateis experienced as being rich withprovision of choice, informationabout the problem, acknowledgementof the patient's emotions and minimalpressure to behave in particular ways,patients display improved physiologi-cal outcomes, in this case glycosylatedhaemoglobin. Furthermore, Williamsand colleagues demonstrated theprocess by which an empoweringconsultation may lead to improvedpatient outcomes. Their prospectivedata indicated that patients whoexperienced a more autonomous sup-portive health care climate reportedmore autonomous motivation. Thatis, they experienced a sense of volition,self-initiation and personal endorse-ment of the self-care behaviour, ratherthan controlled motivation, wherepeople feel pressured to behave bysome interpersonal or intrapsychicpressure. This sense of autonomousmotivation mediated the associationbetween an autonomous health careclimate and blood glucose regulation.

In a review of research into the roleof patient participation in the doctor-patient consultation Golin and collea-gues14 concluded that patient partici-pation was associated with self-care.They hypothesised that increasedpatient participation in the consulta-tion would in¯uence subsequent self-care, by improving the ®t between thetreatment regimen and patient's life-style. This would clearly make it morelikely that the individual will enact thetreatment recommendations. In addi-tion, if patients are permitted tocommunicate their concerns and prio-rities to the provider, they are more

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likely to receive more of the informa-tion they want and need, rather thaninformation that the HCP thinks theyrequire. This will result in greaterrelevance of information, and subse-quent improved use of knowledge andskills. Therefore, it is not surprisingthat a prospective study found a directlink between patient participation andexpression of their views and subse-quent self-care.15

Increased patient participation mayalso result in patients being moresatis®ed with their consultations. Thereview of Golin and colleagues high-lighted a couple of studies thatshowed that increased informationgiving, meeting of expectations andexpression of empathy affect patients'satisfaction with their medical caremore than the costs of careor technical competence of thephysician.16±18 Patients reportedbeing more satis®ed with interactionsin which they expressed their ownopinions.19 Patients also reported feel-ing less motivated to adhere tomanagement strategies when theywere scolded by a provider.20 How-ever, it should be remembered thatsatisfaction is actually the discrepancybetween expectations of the consulta-tion and what actually occurs. There-fore, it is not surprising that somestudies do not report an associationbetween satisfaction and patient parti-cipation, leading Golin and colleaguesto conclude that `the available studiessuggest that patient participation indecision making, assessed in relationto patient's desires for participation,can affect satisfaction'.14

Therefore it would seem that thereis a sound theoretical rationale andincreasing descriptive data to supportthe argument for a more empoweringapproach to consultations. Thisdescriptive data cannot determine thedirection of causality, which can onlybe demonstrated through interventionstudies. However, there are at leastthree intervention studies that providesome support for the principles ofempowerment.

Green®eld and colleagues21 con-ducted a randomised controlled

trial of an intervention designed toimprove patients' participation intheir diabetes care. In a 20 minutesession just before the regular clinicvisit, the participants reviewed theirmedical records with a clinical assis-tant, guided by a diabetes algorithm.Using systematic prompts, the assis-tant encouraged participants to use theinformation gained to negotiate med-ical decisions with the doctor. In thecontrol group the participants justreviewed standardised educationalmaterial. The intervention was suc-cessful in terms of changing the styleof consultation: the experimentalgroup were more active, asked morequestions, spoke more and obtainedmore information. At follow-up theparticipants in the intervention groupshowed signi®cant improvements inglycosylated haemoglobin and hadfewer functional limitations. Further-more, there was a signi®cant cor-relation between more effectiveinformation seeking and follow-upglycosylated haemoglobin. It shouldalso be noted that the increase inpatient participation did not result inlonger consultation.

Building on this work, Kinmonthand colleagues22 conducted a rando-mised controlled trial of trainingprimary care professionals in more`patient-centred' care. The trial wasconducted by encouraging profes-sional carers to review the evidencefor patient-centred care, and providingthem with relevant skills training, suchas active listening and negotiationof behaviour change. In addition,patients in the intervention groupreceived a booklet encouraging themto ask more questions. All newlydiagnosed patients with type 2 dia-betes attending the participating 41practices were then followed for ayear. The intervention participantssubsequently reported better commu-nication with health care professionals,greater treatment satisfaction andbetter emotional well-being. Thesebene®ts were achieved withoutadversely affecting glycaemic control.The authors concluded that the `studyshows the power of the consultation

to affect patients' health and well-being'.

Clearly neither of these interven-tions were overtly based on theempowerment model, and onlyfocused on certain aspects of themodel as described above. However,Anderson and colleagues23 have con-ducted a randomised wait-list controlgroup trial of a patient empowermenteducation programme. This consistedof a six week programme designed toprovide patients with the necessaryknowledge, attitudes and skills to beenable them to be `self-empowering'.In addition to the programme signi®-cantly improving patients' self-ef®cacy(more commonly known as con®-dence), a consistent and powerfulpredictor of self-care behaviour, sixweeks after the programme the inter-vention group showed signi®cantlygreater improvements in glycaemiccontrol than the wait-list controlgroup.

The data from the above studiesindicates that giving patients morechoice, actively listening to them andanswering their questions, in effectempowering them to take care of theirdiabetes, will result in improvedphysical and emotional health. Itmust be noted that to date the authorsare not aware of any study that hasfully tested the empowerment model.There are a number of studies report-ing changes in HCPs' attitudestowards patients having more auton-omy, choice and involvement in theirdiabetes care, as a result of attending`empowerment training workshops'.24

However, there is as yet no data toindicate that this results in changes inHCP behaviour, and that this willresult in improvements in patientshealth. The literature brie¯y reviewedhere suggests that patients' physicaland emotional health will be enhancedif an empowerment model is adopted.As such, there emerges empirical datafor this model of diabetes care, but afull test of the model is needed beforean empowerment approach can beargued for on more than just philoso-phical or experiential grounds.

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4. Evans JMM, Newton RW, Ruta DA, Mac-Donald TM, Stevenson RJ, Morris AD. Fre-quency of blood glucose monitoring in relationto glycaemic control: observational study withdiabetes database. BMJ 1999; 319: 83±86.

5. UK Prospective Diabetes Study Group. Inten-sive blood-glucose control with sulphonylureas orinsulin compared with conventional treatmentand risk of complications in patients with type 2diabetes (UKPDS 33). Lancet 1998; 352:837±853.

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W O R K S H O P N O T I C E

Learning for Life: An empowerment approach to diabetes care

Do you struggle with patients who don’t follow advice?

Do you want to ensure you are using your consultation time effectively?

Do you want to learn more about the philosophy of empowerment and its effect on enhancing self-carebehaviours?

Then you may be interested in this 2 day workshop, with follow-up half day.

The workshop, supported by Abbott Laboratories Medisense Products, aims to increase understanding of theproblems preventing people with diabetes from changing their behaviour, and to practice ways of facilitatingpeople’s ability to solve problems of their own in relation to diabetes self care. It highlights some of the emotionalissues around diabetes, and uses small group work with videos and real-play. A range of tools and methods forself-assessment in practice will be provided, and the follow-up half day will allow participants to reflect on theirsuccesses and some of the barriers to changing practice.

The next workshop is being held on 5–6 October 2000. The cost of the workshop is £200, including onenights accommodation. If you wish to attend, or if you are unable to attend this time but would like to attendfuture workshops, please contact:

Jill Rodgers, Diabetes Nurse Specialist, North Hampshire Hospital, Aldermaston Road, Basingstoke. E-mail:jillrodgers@cwcom.net

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