Health care professionals’ understanding and day-to-day practice of patient empowerment in diabetes; time to pause for thought?

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Abstract

This exploratory study examines what Health Care Professionals (HCPs) working with diabetes patients, understand by the term ‘empowerment’, their attitudes towards it and whether they believe they practise in ways consistent with empowerment principles. A small sample of diabetes HCPs (N = 13), from National Health Service (NHS) hospital, walk-in and General Practitioner (GP) clinics in South-East England, was interviewed. In-depth semi-structured interviews established attitudes towards and use of empowerment in day-to-day practice. Interviews were recorded, transcribed verbatim and analysed thematically. There was no clear specific understanding of what empowerment is and what it involves, although there was broad reporting of factors around education and informed choices. Disagreement was evident about the level of freedom patients should have in making choices – from leading them to the ‘right’ choice to an acceptance that they may have the right to choose not to be empowered. No consensus emerged on what is successful empowerment and how it is measured. The resistance of some patients to the process of empowerment in its original definition of active partnership in care, was seen as problematic by HCPs. Although empowerment is a popular concept in theory, its practical, clinical implementation day to day, can be problematic.

Introduction

Since its original definition as “A process whereby patients have the knowledge, skills, attitudes and self-awareness necessary to influence their own behaviour and that of others in order to improve the quality of their lives” [1] empowerment became a popular topic with policy makers and researchers alike [e.g. 2] in the early 1990s.

Central to the original definition of empowerment is a new role for healthcare professionals (HCPs). This role, sees HCPs as active partners and collaborators with patients, and in shaping patients’ self-management care plans. Such an arrangement, often clashes with an ‘acute-care’ model, [3] where, traditionally, HCPs are seen as experts, called upon to autonomously treat an illness per se.

It is known that HCPs, can find implementing empowerment group education, difficult in practice. In a study with European diabetes HCPs, Adolfsson et al. [4] showed that although diabetes HCPs “knew their role in the traditional approach”, they had problems with empowerment. “As experts they felt secure; as facilitators they needed support” [4]. In similar work by Jones et al. [5], London General Practitioners (GPs) were found to be using shared decision making, a defining feature of empowerment, as a tool to get patients to agree with the HCP's perspective, rather than in its true function of, truly, shared decision making.

We have previously argued [6], [7], [8], [9] that the concept of empowerment is problematic in the inherent assumptions it carries. Thus, empowerment as a concept assumes that HCPs are themselves able, and willing and consciously in favour of, adopting a model that relies on principles such as patient-centred care and shared decision making. We have also shown [10], that diabetes HCPs’ use of empowerment in practice is quite varied; whilst some see empowerment as a rejection of paternalism and an attempt to bring balance and social justice in the HPC–patient relationship, others use the process as a tool to administer (scarce) health-care system resources more efficiently. These findings point to the fact that HCPs practise empowerment in different ways because, perhaps, they have varied and different understandings of what the concept actually means. Given the various definitions of the concept of empowerment, the discussion that has since emerged [6], [7], [8], [9], [11], and the lucidity in thinking and clarity in evidence that has recently been called for in relation to equivocally defining what empowerment is and is not [9], it would not be surprising if we found that HCPs attempting to practise empowerment in a clinic also have a range of views regarding the concept.

It would be interesting to know what HCPs actually understand empowerment to be and how they perceive that they apply empowerment in clinical practice.

This paper presents data from a Diabetes UK-funded study, which explored HCPs’ knowledge and understanding of empowerment in diabetes, the barriers and opportunities professionals faced when practicing it, as well their self-reported support needs. Here, we address two of the larger study's research aims. Specifically, we present data on the following research questions:

  • (1)

    What do HCPs working in diabetes understand by the term ‘empowerment’? and

  • (2)

    Do HCPs working in diabetes apply the principles of empowerment in day-to-day consultations and if so, in what ways?

Section snippets

Methods

The study took place in a moderately deprived area in South-East England with a population known for featuring a highly diverse demographic profile and poorer health outcomes and lower life expectancy than the UK average.

Front line HCPs working with diabetes patients in their daily practice were recruited from hospital diabetes clinics, walk-in health centres and local GP practices. Recruitment was by the researchers introducing the study at diabetes HCP staff meetings, following which,

Results

Data are presented thematically within each area and all responses and quotes are anonymised to protect participants’ identity. Representative quotes are used to illustrate themes. Convergent and divergent experiences and views are highlighted.

Discussion

This was a small exploratory study seeking to understand whether HCPs working with a socially deprived mix of patients in the South East of England, understand the concept of empowerment and how they practise empowerment in day-to-day practice.

The data showed that although there is no clear specific understanding of what empowerment is and what it involves, there is broad acceptance of a range of factors around education and informed choices. Thus, empowerment incorporates providing patients

Conflict of interest

The authors declare that they have no conflict of interest.

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The study was supported by a small grant from Diabetes UK.

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