The concept of empowerment is prominent in many contemporary nursing theories. Nevertheless, without proper understanding, it is sometimes misinterpreted and misused, which undermines its credibility. The aim of the paper is thus to analyze the concept as presented in Peplau’s interpersonal theory. The concept is outlined and evaluated by reviewing the relevant literature. Its attributes, antecedent, consequence, and empirical referents are determined in dedicated sections. Finally, the concept is illustrated by the model case and two alternative cases, where it is described as incomplete and opposite. As a result, the value and relevance of the concept are determined, and the directions of further inquiry are outlined.
Definition and Explanation
Peplau’s theory implicitly identifies empowerment as the readiness of the patient to critically assess the health needs, negotiate the terms of care, and take responsibility for the decision (Hall & Richie, 2014). As such, it is viewed as a way to become independent from professional health care and reach self-sustainability. According to Peplau, the role of a nurse is to facilitate empowerment via communication, empathy, and education, which is largely consistent with the depiction in other sources.
Empowerment is a widespread concept, utilized by many nursing theorists. While its definitions are relatively consistent throughout the literature, its roles differ significantly in different theories. Besides, there is no agreement regarding the weight it has and the degree of patient involvement it requires.
While the necessity of patient involvement was recognized early in the nursing studies, it first was communicated in the form of empowerment concept with the advent of the interaction nursing theories, such as the Peplau’s interpersonal theory. According to Peplau, the patient is a passive recipient of health care only in the initial phase, and this setup needs to be changed as soon as possible (Searl et al., 2014). This is done by educating patients and providing them with the means necessary to decrease the dependence on the professional care. Simultaneously, the nurses are expected to serve as a leader, empowering patients to participate in the decision making relevant to their health and taking responsibility for the decisions. According to Peplau, the empowerment facilitated by the nursing practitioners results in the termination of the relationship between a health care organization and clients once they are both equipped with the relevant knowledge and ready to take action.
Another attempt of utilizing empowerment concept to improve patient outcomes can be seen in Orem’s theory. The premise, in this case, is largely the same, but with additional emphasis on the structure of the organization concept (Pelicand, Fournier, Le Rhun, & Aujoulat, 2015). Orem’s framework suggests the setting which assists the patient in initiating self-care behaviors and decreasing the involvement of clinicians to the necessary minimum. While the leadership practices, in this case, play a secondary role to the organizational means and the patients are encouraged by the approachability of means rather than by the shared vision, the technical and structural means still fit within the empowerment.
Traditionally, the concept of empowerment is associated with improvement in cases of mild severity and is intuitively restricted to rehabilitation and prevention rather than the actual treatment. The most likely reason is the necessity of the professional intervention which cannot be fully substituted with patient participation. Nevertheless, some studies indicate substantial improvements in the treatment process. For instance, a controlled cohort study conducted in 2015 showed visible improvements among patients with type 2 diabetes mellitus. (Wong et al., 2015). The results indicated that a specific patient empowerment program (PEP) was associated with lowered incidence rate of all-causes mortality among the individuals who chose to participate in the program (Wong et al., 2015). Another study evaluated the web-based approach to empowerment, which included comprehensive status reports filled in by patients, logs of physical activities and nutrition, medication record, and messaging tools providing timely advice and support. The results were equally positive, with the patients showing improved outcomes after participating in the program (Tang et al., 2013). It should be noted, however, that both studies dealt with type 2 diabetes among the obese patients.
Obesity is known be dependent on the behavior and thus is addressed by empowerment relatively easily. This should be taken into consideration when projecting the possible outcome of the empowerment program implementation. In fact, while the interventions in the fields related to behavior usually yield positive results, the overall picture is far less uniform. For example, a systematic review of web-based interventions aimed at empowering patients illustrated a far less impressive situation. Of the 19 published studies, only four reported conclusively positive results supported by tangible evidence (Kuijpers, Groen, Aaronson, & Harten, 2013). Besides, 13 out of 19 studies lacked scholarly consistency, being of moderate quality.
Another notable fact is that while most of the elements, such as education, communication with the consulting nurse, self-management, self-monitoring, and logging, were common across studies, the consistency was not present in duration, frequency, and content of interventions. In other words, despite being present in nursing literature for several decades, the concept of empowerment still lacks standardization. One possible reason for this is the absence of clear definition. A mixed-method study conducted by Bravo et al. (2015) assessed 67 articles and identified a high diversity of definitions. While the majority of the definitions relied on the same basic concepts (coherent with those indicated by the study discussed above), the diversity leads us to two assumptions. First, the understanding of the empowerment concept is still unregulated and at least to some degree intuitive. Second, the lack of common ground is at least partially responsible for the uneven results as it likely forbids a clear framework of construction and implementation of the concept.
As can be seen from the theory suggested by Peplau, the concept of empowerment requires communication between parties (Searl et al., 2014). Thus, the concept is characterized by the requirement for mutual effort. The Orem’s theory allows us to expand the notion of communication from the interaction between two individuals to the external environmental influences. The structural changes suggested by Orem can also be viewed as means of communicating the idea of empowerment. Thus, the first notable attribute of the concept is its collaborative nature.
Empowerment is also associated with setting a common goal. While in some cases the goal is projected onto the patient by the nurse, the interpersonal theory also suggests finding common ground by appealing to the existing values. Thus, the second attribute is vision and goal sharing.
The decision making is necessarily associated with the responsibility for the decisions and the accountability for actions. This is a visible barrier to the acceptance of the concept in most theories, but when accepted, it fosters the determination and strengthens the rationale behind the actions. Thus, the third attribute of empowerment is the necessity of accountability.
In most cases, the empowerment is not a one-sided process – instead, it impacts the facilitator. In fact, the active role of the latter weakens over the course of the process, giving way to the initiative of the patient. This aspect, which is intuitively viewed as a drawback, actually creates the opportunity of testing the integrity of the healthcare practice. Similarly, when applied to the workforce, it creates a fairer environment (Bravo et al., 2015). Thus, the fourth attribute of empowerment is its two-directional nature.
Antecedent and Consequence
An identifiable occurrence that needs to precede the empowerment is an interpersonal alliance. Such alliance is fostered when the patient and a nurse find common ground in terms of values and goals. The values can be built upon the pre-existing views or by communicating the relevant new ones to the patient. Simultaneously, trust and mutual respect strengthen the determination of the patient to cooperate. Once the alliance is established, the patient can apply the available knowledge to produce the desired outcome and strive to seek new means of reaching a goal. In other words, the alliance is necessary to create or strengthen determination which is associated with empowerment.
Once empowerment is observed, the patient becomes partially or fully independent of external factors. The knowledge communicated by the nurse (on the earlier stage) or obtained individually (late in the process) is enough to make relevant decisions in the non-specialized fields. More importantly, the patient is ready to participate in the healthcare process, e.g. negotiate the conditions of treatment and acquire the data to fill the gaps and conceive a meaningful picture. Admittedly, the independence is a consequence that is not easily measured since it often requires the involvement of the clinician, the fact which seemingly undermines its integrity. Thus, rather than assess it in terms of the amount of professional assistance involved (which will be different in each case), it should be evaluated by the readiness of the patient to participate and accept the responsibility.
While empowerment is an intangible process, it can be objectively measured. The first referent which indicates the degree of empowerment is the opportunity to make choices (Kuijpers et al., 2013). Within Peplau’s theory, this opportunity can be measured by the level of knowledge the nurses transmit to the patients and the degree to which the latter comprehend it. Both can be done with simple and well-established testing procedures. In Orem’s theory, where the opportunity is structurally determined, the assessment can be done by reviewing the existing tools for independent self-care.
The second referent is the actual use of the opportunities by patients. For instance, while the patients may have a substantial knowledge base and show a high level of comprehension, they may not be ready to use it to their advantage. The most common reason for this is the absence of trust and self-esteem – one of the attributes of empowerment. This referent is usually measured using dedicated interviews, questionnaires, and surveys, possibly backed by observation (Kuijpers et al., 2013), and coded to produce qualitative data.
Scott, a 67-year-old patient, has arrived at the cardiac rehabilitation clinic after the surgery. There he was interviewed by his assigned nurse, Jason, regarding his condition (collaboration attribute). Jason clarified all of the data from Scott’s medical record and explained in simple and clear terms the positive influence of the record keeping (shared goals) and made it clear that Scott can count on support and consultation (the hotline was preferred to the Internet-based communication since elderly patients are traditionally more accustomed to the former). In the end, Jason outlined the chief role of the patient in the process of rehabilitation. The communication was lined with open-ended questions (two-directional nature), which allowed to monitor the patient’s comprehension and to strengthen his involvement. At the end of the conversation, the alliance was formed as Scott expressed the readiness to “do his best” (vision and goal sharing). The comprehension of initial information was confirmed by oral inquiry and writing down the essential actions.
In the subsequent visits, Scott made several inquiries about the physical exercises he was recommended by his friends and asked to confirm their usefulness. His reports became more comprehensive over the course of the week, and on his fourth visit, he was able to provide the appropriate assessment of his physical examination on his own. The consultation topics raised by Scott over the phone were identified by Jason as relevant and at the same time complicated enough to demand professional explanation. Scott’s growing competence is a sign of decline of dependence on Jason, while his decision to approve the PE identifies his ability to make decisions.
After the surgery, Marjorie was consulted on the possible options for the post-surgical treatment. Among other details, Marjorie was briefed on pros and cons of urinary catheter insertion, including the possibility of infection. In the end, she asked for a catheterization. In a week, when the first symptoms of infection were observed, she became extremely hostile and expressed her dissatisfaction with the quality of nursing services.
While it is possible that the reason for the adverse effect was indeed the result of professional negligence, it is evident that the patient was not ready to accept the responsibility for her actions. She is eager to decide the terms of her treatment without considering the consequences, which eliminates the need for rationale and critical approach. The absence of one attribute renders the whole concept of empowerment useless.
A complete opposite case would look like this: a patient who seeks for a consultation continuously gets it, but the information never exceeds the required minimum. No justification is given for the suggested treatments, and the instructions are limited to schedules and dosage. The questions are discouraged with the notion that the patient would do better turning to professionals. Approachable communication means are lacking. Under such conditions, there is no possibility of alliance formation and the patient remains dependent on the establishment and does not have a clear idea of the healthcare process.
The concept of empowerment is widely presented in different nursing theories. The Peplau’s interpersonal theory emphasizes its importance to increase patient involvement and minimize dependence on the professional health care. Other theories view the concept differently but commonly include education, communication, vision and goal sharing, and leadership as its central components.
The common understanding suggests that the concept aligns well with the current nursing policies of patient participation. However, a closer examination reveals the lack of consistency among the theorists and no standards. While writing the paper, I was expecting to gain additional knowledge on the benefits of its implementation. Instead, I have discovered that extensive theoretical analysis is desirable before the concept can be recognized as a meaningful intervention. The preliminary results suggest that it is beneficial even in its current, unsystematic state. Thus, a further theoretical backing is needed to realize its full potential.
Bravo, P., Edwards, A., Barr, P. J., Scholl, I., Elwyn, G., & McAllister, M. (2015). Conceptualising patient empowerment: a mixed methods study. BMC Health Services Research, 15(1), 1-14.
Hall, C., & Richie, D. (2014). What is nursing? Exploring theory and practice. Exeter, England: SAGE.
Kuijpers, W., Groen, W. G., Aaronson, N. K., & Harten, W. H. (2013). A systematic review of web-based interventions for patient empowerment and physical activity in chronic diseases: relevance for cancer survivors. Journal of Medical Internet research, 15(2), 1-18.
Pelicand, J., Fournier, C., Le Rhun, A., & Aujoulat, I. (2015). Self‐care support in paediatric patients with type 1 diabetes: bridging the gap between patient education and health promotion? A review. Health Expectations, 18(3), 303-311.
Searl, K. R., McAllister, M., Dwyer, T., Krebs, K. L., Anderson, C., Quinney, L., & McLellan, S. (2014). Little people, big lessons: An innovative strategy to develop interpersonal skills in undergraduate nursing students. Nurse Education Today, 34(9), 1201-1206.
Tang, P. C., Overhage, J. M., Chan, A. S., Brown, N. L., Aghighi, B., Entwistle, M. P.,..Perkins, A. J. (2013). Online disease management of diabetes: engaging and motivating patients online with enhanced resources-diabetes (EMPOWER-D), a randomized controlled trial. Journal of the American Medical Informatics Association, 20(3), 526-534.
Wong, C. K., Wong, W. C., Wan, Y. F., Chan, A. K., Chan, F. W., & Lam, C. L. (2015). Patient empowerment programme (PEP) and risk of microvascular diseases among patients with type 2 diabetes in primary care: a population-based propensity-matched cohort study. Diabetes Care, 38(8), 116-117.