Empowerment Approach to Diabetes Education:

Promises and Challenges

25 March 2006 (12-13:00)

Society of Nursing Education

Kan, Eva

Shiu, Ann TY

and

Wong, Rebecca

Empowerment: Meaning

A common terminology New public health and health promotion:

Specific meaning The WHO definition (1998)

– Empowerment is a process through which people gain greater control over decisions and actions affecting their health.

Relevance to nursing practice

Tones (1998) Self-empowerment model of health

education (patient education) is suitable for nursing practice in the context of individual or small group education encounters.

This is the area where nursing practice can operationalise the concept of ‘health promotion at the micro level’.

The literature shows a paradigm shift

Diabetes – A chronic illness– Over 95% of decision-making– Self-managed illness– Active engagement of patients– Education as the corner-stone

Diabetes research priority– A cursory MEDLINE search: over 450

citations of compliance in the title (all inclusive = 8000)

– 21st century as an era of researching effective models of diabetes care delivery

– In particular what model of care can better elicit patients’ cooperation

Diabetes education research– A gradual shift since 1990s: from a

traditional/didactic/preventive model to an empowerment approach

– The limitation of the preventive approach: knowledge does not always lead to change in behaviour, e.g., a systematic review 2004

– As exemplar pioneering the shift in the patient education arena

A general agreement at the end of 1990s – Patients as active and informed

participants– A preventive (compliance/adherence)

model is an acute illness model– Empowering patients to take control of

both physiological and psychological outcomes – to be the major underpinning philosophy

of care provision

In the new public health era, a preventive model to patient education is regarded as– Without paying attention to psychosocial

and economic factors– Imposing values– Victim blaming

Victim blaming Consists of

“Ignoring the broader social, material, economic and cultural factors determining individual behaviour and

placing the entire burden of responsibility for action on individuals (victims) themselves while,

at the same time, not recognising the limits to the individual’s power to act and,

on occasions, denying the individual the opportunity to take responsibility when he or she actually has some scope for making choices” (Tones and Tilford, 2001).

Prevention of diabetes complications

Extremely important: A goal of diabetes education

But may become victim blaming – when the environmental factors are ignored or – when patients’ opportunity to take

responsibility and make choices are denied

Facilitating active engagement of patients

The approach to diabetes care should change from compliance to empowerment– does not abandon educating for

knowledge – but goes beyond it

The shift is likely to – enhance knowledge and cooperation – foster appropriate self-management

abilities– enable patients to overcome some of the

personal, social and environmental barriers

An empowerment paradigm

Education strategies derived from the empowerment model may be more effective in achieving prevention of diabetes complications

For example, A randomised control trial study shows that patient empowerment can improve patient outcomes such as HbA1c and QoL (Anderson et al., 1995)

Empowerment as the philosophy

The Anderson team at Michigan started advocating patient empowerment in the 1990s

‘This philosophy is based on the assumption that to be healthy, people need to have the psychosocial skills to bring about changes in – their personal behaviour, – their social situations, and – the institutions that influence their lives.

These skills probably play an important role in the development and implementation of a successful diabetes self-care plan, i.e., a plan that enhances the patient’s health and quality of life’ (Anderson et al., 1995).

Empowerment as the education process

Aims at facilitating patients’ sense of control (confidence) in – Achieving goals – Overcoming barriers – Determining suitable methods – Obtaining support – Coping

Empowerment as the outcome

Include self-efficacy beliefs, sense of coherence, self esteem

To assess the outcome of programmes guided by patient empowerment, a measure of meaning to the philosophy should be used

Anderson et al. (1995) developed and psychometrically tested the Diabetes Empowerment Scale – measures diabetes psychosocial self-efficacy

How to implement empowerment in education encounters

– Clarify and internalise the philosophy Beliefs about diabetes self-management Values and associated beliefs about diabetes

education A deep reflection on the roles and responsibilities

– Develop awareness of the basic assumptions of the use of this and other theoretical models

– Use education strategies of meaning to the self-empowerment model

Two-way communication Mutual respect: two experts Experiential learning activities

Scenarios and Discussions

Some scenarios from our clinical experience

Aim to stimulate discussion on (1) promises and (2) challenges of implementing empowerment

in diabetes education, which may include the constraints arising from – the patient, – the nurse, and – the context