Patient empowerment: A patient-centred approach to improve care

Jones and Meleis describe the concept of empowerment as a “social process of recognizing, promoting, and enhancing people’s abilities to meet their own needs, solve their own problems, and mobilize necessary resources to take control of their own lives.” In other words, patient empowerment is a process of helping people to assert control over factors that affect their health.

There is a strong link between the concept of empowerment and that of development of the community. The World Health Organization (WHO) health promotion glossary distinguishes between individual and community empowerment—individual empowerment refers primarily to the individual’s ability to make decisions and have control over his or her personal life; community empowerment involves individuals acting collectively to gain greater influence and control over the determinants of health and the quality of life in their community.

Community empowerment becomes an integral element of the health care reform movement. Given the escalating costs of health care, the wider involvement of the general public in policy-making, as well as taking more responsibility for maintaining their own health, with a move towards increased public responsibility in health care management, are also means of cost-containment. The basis underlying all such involvement is the need for a patient to take an informed stance and make an informed choice. This involves not only health care professionals interacting with patients, but also a conscious effort at the policy-making level to ensure that such informed participation is possible. Patient charters and patient empowerment acts have been drawn up, for example in the US, to ensure that people have the right to self-determination and power over their health decision.

From the biomedical model to the patient empowerment model of care

Health care providers need to surrender the need for control and involve patients in making care decisions and exert control over his/her health needs. Gibson compared the traditional biomedical model of care with an empowerment model of care. The latter illustrates the kind of shift in thinking required to allow empowerment to take place.

In the past, patients were supposed to be compliant (obedient) with a health care professional’s directives—the biomedical model. In this model, when a treatment plan fails, it is often the responsibility or the fault of the patient. Persuasion and manipulation (coercion) are the primary communication strategies for attempting to make patients manage their illnesses. Experience has shown that these strategies are simply not efficient, especially for patients with chronic diseases. This is particularly true for patients who remain ambivalent about changes that may need to be made or lack the confidence to make the necessary changes. In fact, these strategies cause patients to defend the very behaviours the health care professional is trying to change.

In the empowerment model, the term used is adherence. Adherence implies a contract between patients and providers in whom joint responsibility is taken for achieving agreed-upon outcomes. In the empowerment model, health care professionals respect the patient and assist the patient in making decisions in ways that have meaning to the patient.

Patient autonomy is seen as relational rather than independent. Patients are encouraged to act autonomously through shared information and mutual collaboration in decision making. Understanding how patients view their illnesses and treatment has been shown to be positively related to treatment adherence and produces better outcomes.

In the biomedical model, patients who are resistant or who don’t comply with the treatment plan are viewed a difficult patients. Resistance is seen as bad and something to be eliminated. In the empowerment model, resistance is seen as giving valuable information. The health care professional needs to explore resistance with the patient, to discuss reasons for their resistance, to identify possible solutions, and to mutually plan for change.

The empowerment model distinguishes confronting from arguing in that, in a confrontation, no judgements are made about the patient’s behaviour. If an adherence problem with medication exists, the pharmacist would explore potential solutions with the patient rather than giving a lecture on the importance of taking the medication. The empowerment model is thus one of mutual respect. The respect derives from the valuing of human life and the building of a good clinician-patient relationship.

Translating the concept into daily practice

The patient empowerment movement started in the early 1970s, advocating the rights of the patient. The goal of patient empowerment is to build up the capacity of patients to help them to become active partners in their own care, to enable them to share in clinical decision making, and to contribute to a wider perspective in the health care system.

The empowerment process can be achieved through training and support. There are ranges of options available including providing information sheets, multimedia programs, use of information technology, and skill building such as a diabetes self-management programme. The essential attribute for these programmes lies in respect for the patient’s unique and valuable perspectives rather than training the patient to shadow the health care professionals. The initial step in gaining respect and meeting patient’s needs or preferences is to solicit their views and listen to what they say. Multiple studies have demonstrated that patients who are involved with decisions about their care and the management of their conditions have better outcomes than those who are not involved.

Physician’s views on patient empowerment are also positive, in that encouraging patients to be partners will lead to faster shared understanding, greater patient satisfaction, and improved health outcomes. The concept of ‘patient as partner’ is essential for efficient doctor-patient consultations, in which mutual understanding leads to rapid diagnosis and negotiated treatment options that are more likely to be adhered to.

Informed consent is considered a tool for patient empowerment. Edge and Groves identify the stages that characterise informed consent as including:

1. disclosure—the patient should be informed of the nature of the condition, the various options, potential risks, the professional’s recommendation, and the nature of consent as an act of authorisation;
2. understanding—information is provided at the patient’s level of understanding, using appropriate language;
3. voluntaries—the patient must be in a position to practise self-determination free from any coercion, manipulation, or constraint;
4. competence—based on the patient’s past experience, maturity, responsibility, and capacity for independent decision making; and
5. consent—a freely given authorisation to the medical or nursing intervention.

To enable patients to express their informed preferences, patients must be given sufficient and appropriate information, including detailed explanations about their conditions and the likely outcomes with and without treatment. It is, however, frequently heard that patients express difficulties in obtaining information relevant to their needs.

There are various reasons for this. Health care professionals might have underestimated a patient’s desire for and ability to cope with information. Consultation times are limited and thus there is often insufficient time to fully explain the condition and the treatment choices. The extent of the information to be given to the patient is difficult to decide. Too much information may deter the patient from having necessary treatment.

As noted above, the ways in which information is delivered and the kind of materials given to the patient are of particular importance to support a patient’s involvement in treatment decisions. Coulter et al, in their study on information materials given to patients, found that the available information for patients omitted relevant data, such as failing to give a balanced view of the effectiveness of different treatments and ignored uncertainties. Many information materials adopt a patronising tone and few actively promote a shared approach to decision making.

Information should therefore be made simple in order to maximise its comprehension and to minimise any potential imposition of the professional’s view. An interval should elapse between the presentation of the advantages and possible disadvantages of the proposed treatment and the patient’s decision, so that there is an opportunity for the patient to consider the decision, to ask further questions, and to discuss it with family and significant others.

Drawing on overseas experience

In the UK, there is a shift in the balance of power to greater involvement of patients in health care. The publication of ‘Involving patients and the public in healthcare’ in September 2001 by the Department of Health in the UK has set out proposals for implementing the vision of patient centred care in the National Health Service (NHS). The voices of the patients, their carers, and the public are heard and listened to at every level of the service, which acts as a lever for change and improvement.

‘Crossing the quality chasm’, a second report from the US Institute of Medicine in 2001, highlighted the deficiencies in health care quality in the US and made recommendations for improvement. Patient centredness is one of the key dimensions for improvement.

The global change towards patient empowerment and increased patient involvement is in line with a focus on health rather than on disease, on prevention and health education rather than on cure, and on trying to make people aware of the choices they have in relation to their health. The change represents a step towards the achievement of a more generalised sense of responsibility of patients and the public.

Locally, more measures can be considered for patient empowerment and building a good clinician-patient relationship—improving the information given to patients, including treatment options, outcomes, and limitations in medical care, and encouraging informed choice and shared responsibility. Strengthening the complaint procedures and introducing patient forums, patient advocacy, and liaison are other measures to enable patient’s perspectives and views to be known for planning their own care and for service planning at a strategic level. The outcome will help to promote patient-centred care and hopefully to reduce health care costs.

Medical knowledge has long been used in clinical practice for professionals. It is time to shift the balance of power to include patients and their carers. Patient empowerment is intended to enable patients to make judgements about their own illness and to be fully responsible members of the health care team. Patients are seen as experts of their illness and health care professionals as experts on the medical conditions and management resources. Combining both and sharing the expertise could achieve the intended platform for managing illness.

Patients are encouraged to manage their own health care through prevention and lifestyle changes leading to improved participation and satisfaction both in the short and long term. The capabilities that patients have for identifying risk and managing events to slow the progress of their condition help to prevent medical crises before they happen. The Institute of Medicine report ‘To err is human’ found that up to 98 000 Americans die every year from preventable medical errors and recommended that measures be taken to improve quality and safety. Educating patients in safety practices, for example knowledge of medication that could help to prevent medication errors, will create a market that demands and supports safety.

The key elements of empowerment are knowledge, behavioural skills, and self-responsibility. To ensure the success of patient empowerment, enhancement of the working partnership between patients and health care professionals is important. Finding out what matters to patients, making use of information technology to disseminate knowledge, establishing standards for disease management, and promotion of clinical research are likely to increase the benefit of the health care provided.