Self-empowerment In Health Promotion 236h56

Clinical

Self-empowerment in health promotion: a realistic target? Nici Mackintosh There have heen many calls for nurses to adopt a self-empowerment model for health promotion practice rather than continuing to work from the medical model. Continuing with our series on health promotion, this article examines features of the self-empowerment approach and questions whether its goals are achievahle.

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4lh he term 'health promotion' is 'very difficult to pin down for descriptive purJLh((Beattie, 1991). In this article, it is poses' accepted that health promotion includes: '...both health education and all attempts to produce environmental and legislative change conducive to good health' (Dennis et al, 1982). While health promotion involves the alternative and complementary processes of social engineering and health education, the latter is about facilitating health choices: 'Health education is concerned with raising individuals' competence and knowledge about health and illness, about the body and its functions, about prevention and coping; with raising competence and knowledge to use the health-care system and to understand its functions; and with raising awareness about social, political and environmental factors that influence health* (Baric, 1985).

Strategies for health education

Nici Mackintosh is Senior Clinical Nurse at Sandwell Healthcare NHS Trust, West Midlands

Health education takes different approaches. In an effort to examine the practical implications and goals for each strategy, many authors have attempted to devise classifications for these approaches (e.g. Tones. 1981, 1986; Beattie, 1982, 1991). Five classifications for such approaches can be identified {Table 1). Research studies (Johnston, 1988; Latter et al, 1992; Mackintosh, 1993) have confirmed that the majority of nurses persist with the behavioural change approach. Gott and O'Brien (1990) place responsibility for this situation on individualistic ideologies and limited health promotion programmes and policies for health in nursing which emphasise frameworks of individualistic action at the expense of collective nursing philosophies.

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Critics of the behavioural change model point out that it assumes that lay people believe the 'experts' know best. The model imposes medical values on the individual and may also impose feelings of guilt if the client chooses nor to follow the regime. Moreover, in of a violation of respect for the individual's autonomy, there are ethical objections to its assumption that professionals have the right to decide what constitutes 'healthy behaviour'. Both the behavioural change and educational approaches embrace the existential belief that; 'People are born free and create themselves by means of their decisions and choices' (Jacob, 1994). Individuals are perceived as free to choose a course of action and are therefore considered responsible for their health. This individualistic concept of health has been strongly criticized as it fails to take adequate of the social and economic determinants of ill-health and healthrelated behaviour outside an individual's control. The social action approach views human nature from the determinist perspective. Determinists believe that a person's freedom is limited by biological, psychological and social forces. These cause factors such as race, gender, social class and genetics to become the determinants of health. This strategy not only addresses the fundamental social issues underlying disadvantage and ill-health, but also can be regarded as coercive for it seeks to perpetuate a particular political view of society (Tones, 1986). Furthermore, it seems naive to place total responsibility for health on the state. Whereas the government has a duty to create facilities for health, it is still up to the individual to act upon information in a

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Self-empowerment in health promotion: a realistic target? Table I. Strategic approaches for health education Behaviour change (preventive or traditional approach)

Focus: the individual Goal: to persuade the individual to adopt a particular lifestyle/adhere to medical advice to prevent/limit disease and reduce mortality/morbidity rates Rationale: curative medicine cannot cope with current rate of disease. Prevention better/cheaper than cure Evaluation: measured on whether or not the individual adopts a particular lifestyle or changes his/her behaviour Example: advising/persuading the individual to give up smoking

Educational approach

Focus: the individual Goal: to help the individual develop his/her knowledge and skills and explore his/her attitudes, so that he/she can make an informed choice about his/her health Rationale: education is about rationality and freedom of choice Evaluation: measured on the facilitation of decision-making, irrespective of the nature of the decision actually made Example; presenting the individual with the facts about smoking and leaving the individual to make a choice

Social action, radical, social change approach

Focus: the environment at societal level Goal: to make healthy choices the easy choices by changing the physical and social environment so that individuals are enabled to adopt healthy behaviour. Also aim to raise individuals' awareness and involvement in health issues in order to stimulate the demand for social change Rationale: the root of health problems lies in social, economic and political factors Evaluation: measured on the implementation of critical consciousnessraising, and/or social, political or environmental change conducive to health Example: campaigning for smoke-free areas, lobbying parliament for an advertising ban on tobacco

Self-empowerment, humanistic approach

Focus: the individual Goal: to facilitate decision-making by modifying the individual's self-concept and enhancing self-esteem Rationale: by developing motivation, setf-confidence and skills, the individual is in a better position to identify his/her own health needs and take action to meet them Evaluation: measured on the acquisition of life skills and decision-making skills Example: enabling the individual to identify why he/she smokes, helping the individual to develop the confidence and skills needed to make a choice and implement a health plan

Community development approach

Focus: a group Goal: to help a group work together, find its common interests and fight its particular health cause Rationale: it is better to work from the group's valuable experiences rather than to work from a professionally defined agenda Evaluation: measured by successful public awareness raising of the group's concerns and the implementation of health action for the benefit of the group Example: identifying a need for a self-help group, facilitating the group, acting as resource and er for the group

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Self-empowerment in health promotion: a realistic target? ^Within the hospital setting it is often much harder to empower the individual because of the nature of the institution itself. However^ on a smaller scale, the nature ofpersonal interactions between nurse and patient can play an important part.'

way that he/she thinks best. A social action strategy may fail to provide the individual with the motivation to internalize the values it promotes or to promote autonomous self-care. An approach involving the pursuit of self-empowerment facilitates informed choices which are so hard to achieve with the educational approach. A self-empowerment strategy aims to: • Promote beliefs and attitudes favourable to deferring immediate reward for more substantial future benefit • Increase internal control and selfesteem and develop social skills, e.g. assertiveness (Tones, 1981) Thus, the onus is on the individual, but because the self-empowerment strategy aims to help learners become more selfassertive, tbe individual is able to develop a notion of being in control. A selfempowered person is better able to resist pressures to smoke (Tones, 1986) and has more understanding and control over social, economic and political forces. The community development approach shares many features of the self-empowerment approach, but it is on a larger scale. Whereas the self-empowerment approach is limited to developing the individual's ability to deal with social injustices, the community development approach allows certain groups to work together to fight for their health needs. *If nursing is to take health promotion seriously it must be actively concerned with the empowerment of clients and patients' (Tones, 1993). Recognition of the criticisms levelled at the behavioural change model, together with recent interest in holistic and clientcentred nursing, has resulted in a change of focus in health promotion in nursing towards the theory of self-empowerment.

Theory of self-empowerment There are four factors which Tones (1993) considers central to the concept of empowered action for the individual: 1. The environmental circumstances which may either facilitate the exercise of control or, conversely, present a barrier to free action 2. The extent to which individuals actually possess competencies and skills which enable them to control some aspects of their lives, and perhaps overcome environmental barriers British Journal o( Nursing, 1995. Vol 4, No 21

3. The extent to wbich individuals believe themselves to be in control 4. Various emotional states or traits which typically accompany different beliefs about control — such as feelings of helplessness and depression, or feelings of self-worth. One of the criticisms against the educational approach is that the mere understanding of a health issue is not enough to precipitate health action. The provision of information needs to be accompanied by processes of belief and the clarification of values, followed by some practice in decision-making — usually in a simulated setting. For self-empowerment to occur, a developmental programme is required, aimed at certain aspects of personal growth. Two important personality characteristics central to this process are selfesteem and locus of control (Tones, 1986). Self-empowerment in practice Many nurses concerned with community development are involved in empowering both individuals and groups. The agenda is frequently set by individuals within the community rather than by the professionals, and the role of the nurse is not that of an expert, but of a facilitator and partner. For example, the school nurse may respond to teenagers' requests to run a workshop on coping with the problem of peer pressure to experiment with drugs, or a practice nurse may set up a self-help group to help individuals deal with stress. Igoe (1993) and Walker (1993) provide further examples of community settings with the potential for self-empowerment strategies. Within the hospital setting it is often much harder to empower the individual because of the nature of the institution itself. However, on a smaller scale, the nature of personal interactions between nurse and patient can play an important part. By respecting the individual's wishes and allowing the patient the right to choose, the likelihood of disempowering the mdividual is minimized. Believing that one has some kind of control over one's life is beneficial in many ways (Tones, 1993). However, merely having the belief that one is in control is not generally sufficient for the empowerment process to begin; the individual must also be provided with the competencies needed to achieve his/her goals. Wilson-Barnett (1993) noted that enabling people to maximize their individ-

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Self-empowerment in health promotion: a realistic target? How many nurses are in a position to give adequate quality time and privacy, in a suitable erivironmenty to enable the personal development of a patieritf Nurses ofteii take on tbe role of Jianied nurse for a number of patients and are unable, due to lack of time, to build up the deptb of relationship necessary to develop patients' life-skills and potential for managing tbeir own health.

ual potential should be the aim of many .\j;encies (statutory and voluntary) and 'health professionals may be in a special situation lo influence this'. But are nurses in a position to facilitate patients' personal j^rowth? In order to examine this question, the location of the empowerment process withm the context of the counselhng relationship must be established. Person-centred counselling It is possible to draw a parallel conclusion between certain characteristics of the person-centred counselling relationship of the client and counsellor and the relationship established in a self-empowerment strategy. Person-centred counselling places high value on the individual's experiences and the importance of the individual's subjective perceptions of reality. It challenges each person to accept responsibility for his/her own life, and to trust the irmer resources available to all those who are prepared to develop self-awareness and self-acceptance. The notions of self-empowerment and person-centred counselling both fit into the category of a 'helping relationship*, as defined by Rogers (1967): 'A helping relationship is one in which at least one of the parties has the intent of promoting the growth, development, maturity, improved futictioning, and improved coping with life of the other.' They also emphasize the importance of unleashing the power that lies within the individual rather than relying on the authority of the expert.

Table 2. People involved in health promotion Town-planners Agriculturalists Industrialists and businessmen Politicians Those involved with communication and mass media Environmental health workers Directors of transport services Educationalists and social workers Medical and heatth-care professionals Source: Tones (1966)

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It therefore follows that many of the conditions necessary for the development of a therapeutic relationship between counsellor and client may also be required to foster a growth-conducive climate between patient and health-promoter. However, on closer examination, the fulfilment of these conditions is likely to be seen as problematic within certain fields of nursing. First, how many nurses are in a position to: • Be genuine? • Offer unconditional positive regard and total acceptance? • Feel and communicate a deep empathic understanding towards the patient? Yet the counsellor must demonstrate these qualities in order to facilitate the personal growth of the client (Rogers, 1967). Second, the client voluntarily chooses to form a relationship with the counsellor. The patient, on the other hand, is often forced to form some kind of relationship with the nurse. There is still the element of choice as to what form this relationship should take, but he/she may may not wish to take responsibility for his/her own health. How many nurses are in a position to give adequate quality time and privacy, in a suitable environment, to enable the personal development of a patient? Nurses often take on the role of named nurse for a number of patients and are unable, due to lack of time, to build up the depth of relationship necessary to develop patients' life-skills and potential for managing their own health Thus, we need to question the feasibility of setting self-empowerment as a goal for nursing practice. It is questionable whether the majority of nurses are in a sufficiently credible and empowered position themselves to be able to facilitate selfdiscovery in others. How many nurses have access to networks and opportunities for guidance from qualified experts to deal with emotionally threatenmg situations? There is an additional problem for those nurses working within the hospital structure. The management of health and welfare issues has traditionally been placed in the hands of experts, located within large, centralized bureaucracies. In a system that calls for dominance by professionals, it is difficult to achieve egalitarian working relationships. A call for actively participative roles for patients challenges the existBritish Journal of Nursing. 1995. Vol 4, No 21

Self-empowerment in health promotion: a realistic target? ing power/control base (Kcyzcr, 1988). There is the added danger that, in an attempt to adopt a facilitative approach, activities which arc, in reality, manipulative and defined by the nurse's agenda can be labelled as participative. Similarly, many of the measures for evaluation of health promotion success — within both community and hospital settings — are still defined by the behavioural change approach. It is hard for nurses to work within a model of self-empowerment when their work is often evaluated by compliance rates and evidence of 'positive' changes in lifestyle (Mackintosh, 1996). There is also a danger that nurses will focus on those patients who are receptive to and at ease with the notion of taking control for themselves. These patients are likely to be in the higher social classes. In effect, this actually perpetuates social inequality and maintains the status quo: '...the greatest beneficiaries being those who are already well able to cater for their own health needs, and who have the power and social influence to change things further to their own advantage' (Campbell, 1993). The definition of self-empowerment also involves the facilitation of some exercise of control over the environment. It is questionable how many nurses are in a position to do this.

KEY POINTS • There are three individualistic health education approaches: behaviour change; educational; and self-empowerment. • Traditionally, the focus in health education in nursing has been one of behavioural change. • More recently, many authors have advocated a move towards a self-empowerment approach for nursing. • Due to the constraints of the working environment and nurses' lack of skills, it is often unrealistic to expect the majority of nurses to be in a position to empower and faciiitate the personal growth of a patient. • It is important to acknowledge that nurses are in an important position as providers of information, not as indoctrinators or advisors, but as carers. • Nurses have a duty to acknowledge the social structural facet of health.

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Setting new targets It is important not to lose sight of the. fact that the list of those involved in health promotion is extensive {Table 2). Once it is acknowledged that health professionals actually play a relatively marginal role in health promotion within the wider context of public health, it may be easier for nurses to re-cvaluate the aims of their practice. After all: 'Health promotion must use a wide variety of complementary strategies' (World Health Organization, 1984). All health education strategies should be recognized as having their own degree of importance, since health can only be promoted in society when an amalgam of different approaches are applied. Therefore, the aims of health promotion practice for nurses should be: • To strive for unconditional acceptance of the health values of individuals • To show consideration of the environmental and social factors affecting individuals • To offer health information which should not take the form of indoctrination, advice, or persuasion. Nurses need to be aware that it is almost impossible to give information that is totally devoid of value judgments. Thus, nurses need to develop their communication skills and examine their position as providers of information. Health promotion practice for nurses should therefore take the form of: • Valuing individuals and their health beliefs • Showing sensitivity to the environmental, social and economic factors affecting the health status of individuals • Providing health information • Constantly evaluating and reviewing the accuracy of available health information • Raising individuals' awareness of the social, economic and environmental determinants of health • Informing individuals of their rights, and how to access other services • Involving individuals in decision-making whenever possible • Offering to individuals by mobilizing appropriate resources and liaising with appropriate professionals • Respecting individuals' rights to choose their own courses of action for health • Uniting with other nurses to ensure that professional bodies lobby for good public health poUcies.

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Self-enipowerinent in health promotion: a realistic target? Conclusion Whereas those nurses who are in a position to facilitate personal growth in patients should be encouraged to do so, it is important not to exclude those who are not. Therefore, all nurses should be encouraged to assess their roles as carers, and to review their relationships with patients from the perspective of their potentially powerful positions as health professionals and information-givers. In this way, nurses can use approaches which take note of social structure factors while focusing on individuals' needs and their personal resources. Baric L (1985) The meaning of words: health promotion.; Inst Health EdHc2ii\): 367-72 Beattie A (1982) Changmg Codes of Health. Seminar Notes. Institute of Education, University of London Beattie A (1991) Knowledge and control in health promotion: a test case for social policy and social theory. In: Gabe J, Calnan M, Bury M. eds. The Sociology of the Health Service. Routledge, London: 162-202 Dennis J, Draper P, Holland S, Shipster P, Speller V and Suntcr I (1982) Health Promotion in the Reorganised NHS. Unit for Study of Health Policy, London Campbell A (1993) The ethics of health education. In: Wilson-Barnett J, Macleod-Clark J, eds. Research in Health Promotion and Nursing. Macmillan Press, Hampshire: 2-8 Gott M, O'Brien M (1990) The role of the nurse in health promotion. Health Promotion Int 5(2): 373 Igoe J (1993) Healthier children through empowerment. In: Wilson-Barnett J, Macleod-Clark J, eds. Research in Health Promotion and Nursing. Macmillan Press, Hampshire: 145-53

Jacob F (1994) Ethics in health promotion: freedom or determinism? BrJ Nurs 3(6): 299-302 Johnston I (1988) A study of the promotion of healthy lifestyles by hospital based staff. Unpublished MSc thesis, University of Birmingham KeyZL-r D (1988) Challenging role boundaries: conceptual frameworks for understanding the conflict arising from the implementation o t t h e nursing process in practice. In: White R, ed. Political Issues in Nursing: Past, Present and Future. Vol 3. Wiley and Sons, Chichester, 95-119 Latter S, Macleod-Clark J, Wiison-Barnett J, Mabin J (1992) Health education in nursing: perceptions of practice in acute settings./-4(/i;M
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