Client Empowerment: A concept Analysis

Abstract

Aim: To present a concept analysis of client empowerment from the perspective of Community Health Nursing. Background: The concept of empowerment is broad and is often seen as a way of giving more to the powerless in many facets of life. However, less emphasis has been placed on empowerment of client seeking health care in general and in particular those seeking it at the primary level. Hence, this concept paper analysed client empowerment in community health nursing as most literature on empowerment in nursing mainly dwell on nurses and hospitalised patients' empowerment. Design: The method used in this paper was the approach of Walker & Avant (2011). Data Sources: This concept analysis was carried out with the aid of literature on client empowerment obtained through the internet databases of CINAHL, PUBMED, BIOMED and PsycINFO. The key words of interest were "Client empowerment," "Nurses", and "Empowerment." The search timeline was adjusted to articles published within 2010 to 2015. Review Method: This concept analysis was performed using the 8-step method Proposed by Walker and Avant. Results: Following the Walker and Avant's method, identification of the attributes, antecedents and consequences of Client empowerment led to an operational definition of the concept of client empowerment as a process by which the Community Health Nurse and her client institute a therapeutic relationship within a supportive social climate characterised by respect, mutual decision-making, and power sharing leading to client independence, increased confidence, self-reliance, and self-management. Conclusion: This concept analysis was able to show that, client empowerment is the best way to institute the therapeutic nurse-patient relationship. Client empowerment will facilitate the practice of community health nursing; improve client confidence and satisfaction of health services rendered by nurses. This analysis can be expanded by additional analysis to gain new understanding of the concept, thereby adding to the body of nursing knowledge.

Headnote

Abstract

Aim: To present a concept analysis of client empowerment from the perspective of Community Health Nursing.

Background: The concept of empowerment is broad and is often seen as a way of giving more to the powerless in many facets of life. However, less emphasis has been placed on empowerment of client seeking health care in general and in particular those seeking it at the primary level. Hence, this concept paper analysed client empowerment in community health nursing as most literature on empowerment in nursing mainly dwell on nurses and hospitalised patients' empowerment.

Design: The method used in this paper was the approach of Walker & Avant (2011).

Data Sources: This concept analysis was carried out with the aid of literature on client empowerment obtained through the internet databases of CINAHL, PUBMED, BIOMED and PsycINFO. The key words of interest were "Client empowerment," "Nurses", and "Empowerment." The search timeline was adjusted to articles published within 2010 to 2015.

Review Method: This concept analysis was performed using the 8-step method Proposed by Walker and Avant.

Results: Following the Walker and Avant's method, identification of the attributes, antecedents and consequences of Client empowerment led to an operational definition of the concept of client empowerment as a process by which the Community Health Nurse and her client institute a therapeutic relationship within a supportive social climate characterised by respect, mutual decision-making, and power sharing leading to client independence, increased confidence, self-reliance, and self-management.

Conclusion: This concept analysis was able to show that, client empowerment is the best way to institute the therapeutic nurse-patient relationship. Client empowerment will facilitate the practice of community health nursing; improve client confidence and satisfaction of health services rendered by nurses. This analysis can be expanded by additional analysis to gain new understanding of the concept, thereby adding to the body of nursing knowledge.

Keywords: concept analysis, nursing, client empowerment, power, and knowledge.

Introduction

Empowerment is a conventional concept in nursing (Lawn, Delany, Sweet, Battersby & Skinner 2014; Muniz, 2010; Rao, 2012), but most of the literature dwells on nurses and hospitalised patient's empowerment (Bradbury-Jones, Irvine and Sambrook, 2010). In fact, so much of the empowerment literature in nursing has been focused on nurses and only recently has it been applied to patients (Rao, 2012), still, the patients are usually the hospitalised ones.

For this reason, this paper discussed client empowerment in relation to community health nursing, and according to Cawley and McNamara (2011), there has been a modification in the role of the community health nurse from that of curative role to population health and health promotion. These new roles connote that the community health nurse is expected to empower and advocate for her clients, further necessitating this concept analysis. In community health nursing, the word "client" could refer to the individual, family, community or the entire population. This paper, therefore, substituted client for them.

Aim

The aim of the concept analysis was to review literature from different disciplines that have used the concept of client empowerment to furnish an operational definition that applies to community health nursing practice.

Uses of the Concept

Literature Search Processes

This concept analysis was carried out with the aid of literature on client empowerment obtained through the internet databases of CINAHL, PUBMED, BIOMED and PsycINFO. Walker and Avant (2011) advised that all uses of the concept of interest should be reviewed in order to find common themes of the concept. Hence, literature articles from physiotherapy, community psychology, feminism, nursing, complementary and alternative medicine (CAM), and marketing were reviewed. The exercise produced initial results of 14,318 articles. This was later reduced to 47 articles after the search timeline was adjusted to articles published within 2010 to 2015, removal of duplicates and incomplete articles. Furthermore, the articles were sieved to 14 after articles that passively referred to empowerment in their contents were removed. See figure 1. All articles were written in English language.

Thesaurus and Dictionary Definition

Dictionary.com Unabridged (n.d.), defined empower "as to give power or authority to; to authorise, especially by legal or official means, while empowerment is the process or result of being empowered." Roget's 21st Century Thesaurus (n.d.) included the following as synonyms of empowerment; permission, consent, assent, agreement, and rubber stamp.

Etymology of Empowerment

According to Roget's 21st Century Thesaurus (n.d.), empowerment has been in existence since the 17th century. Later in the same century, 1690 to be precise, William Penn, the man whom the present US state of Pennsylvania was named after, popularized it. But its modern usage has been attributed to different era of the last century. While Rao (2012) traced it to the 1960s during the time of the civil right movement in the US, Roget's 21st Century Thesaurus (n.d.) said it was around 1986 that it became popular again.

Empowerment from Various Disciplines

The meaning of empowerment is vast depending on the discipline where it is applied (Bradbury- Jones et al, 2010; Mehta & Sharma, 2014), because it is one of the most used concepts (Mehta & Sharma, 2014). This vastness has made it to lost its true meaning (Cattaneo, Calton & Brodsky, 2014; Cawley & McNamara, 2011; Mehta & Sharma, 2014), and therefore, has been manipulated by those who are supposed to empower others to suit their own goals (Jones, Latham & Betta, 2013).

Various definitions of empowerment abound because the concept is used in most disciplines. From women development, Mehta and Sharma (2014), defined empowerment as a process whereby a leader delegates powers to a non-leader to represent him. According to them there is power sharing and willingness to give it away. Mehta and Sharma believed that empowerment of women make them to contribute meaningfully and efficiently to development because it imbued the spirit of initiative, innovation, liberation and accountability in them. And when women who worked in organisations are empowered, they develop a feeling of belonging, satisfaction, responsibility and fulfillment, and these feelings help promote the organisational performance (Mehta & Sharma, 2014), Arogundade and Arogundade (2015) also shared this view but from a general perspective - that is, both men and women employee.

From a marketing perspective, Fuchs, Prandelli and Schreier (2010, p. 66) defined "empowerment as a strategy used by firms to give customers a sense of control over a company's product selection process, allowing them to collectively select the final products the company will later sell to the broader market." Their definition emphasised customer's control and companycustomer collaboration. Since customers were allowed to participate in the product selection process, the product became psychologically valuable to them and they developed attachment to the product, which Fuchs et al termed as "psychological ownership." Therefore, if empowerment is to take place, customers need to be given more information and choice; and the more customers feel psychologically attached to a product, the more the demand for the product (Fuchs et al., 2010).

Kulik and Megidna (2011), another feminist, noted in their study on psychological empowerment among women volunteer and women client that for empowerment to truly take place, there must be a high quality, social interaction between volunteers and clients. Social interactions are needed to create social relationships that build confidence, which ultimately empowers both volunteer and client. They concluded that to promote empowerment in volunteer organisations, a "supportive social climate" and consensus goals must be encouraged as these bring about positive interaction and strong emotional bonds.

Types of Power

Kulik and Megidna (2011) went further to describe two types of power: power with others - this involves sharing of power and freedom to take initiatives. It is this type of power that promotes empowerment (Mehta & Sharma, 2014). The other type is power over others, which Kulik and Megidna described as "the traditional model of relationships between men and women in the society." In this type of power, there is dominance and submission. According to Jones et al. (2013), some companies are run like this but still call it employee empowerment.

Other Perspectives

Jones et al. (2013) believed that employee empowerment in most organisations is just "rhetoric" and not real because hierarchy still prevails. They described empowerment as a process that includes consensus decision making, participation and teamwork, but argued that these processes are not being practiced by most company's management. Rather most company's management operates an autocratic decision making process that discards workers input so long as it does not fit their own ethos; in other words, the decision making process is twisted to look like employee empowerment.

Cattaneo et al. (2014), viewing client empowerment from a community psychology angle, said that it is wrong to ascribe any action that is aimed at helping a person or community as empowerment, unless if the help is helping a person or community to help themselves, to focus on their strength rather than exploiting their weaknesses and identifying societal structures that give more power to some than others.

Empowerment must be relevant in interventional goals for those who really need them and there must be a genuine transfer of power. This power is social power, which according to them, must be shared between the provider and client, client's needs must be prioritised, and client should be allowed to make a choice from different options and should have contribution to those options (Cattaneo et al., 2014).

Sharing of social power means there is going to be a shiftin "status quo" from a system that has disenfranchised the people. Cattaneo et al. (2014), emphasised that status quo is an impediment to empowerment because the main aim of empowerment is social justice and by status quo they meant a system whereby social power lies with the provider, who calls the shot. It means as long as the status quo is not challenged, empowerment cannot take place. The role of the provider in empowering the client is sacrificing personal power to promote a shifton social power (Cattaneo et al., 2014).

From the complementary and alternative medicine perspective, Bann, Sirois and Walsh (2010) tagged empowerment as a support that is provided to people in the form of enablement and motivation in order for them to take the needed steps to manage and improve their health in a self-directed manner. It is patient-centered and all that is needed from the provider is quality support and that the process of empowerment is cyclical requiring a therapeutic relationship with empathy. The therapeutic relationship creates empowerment which helps in symptom relief. Relief of symptoms increases patients' sense of control over symptoms and build trust in the provider. Once provider's trust is earned, patients are motivated to continue treatment and other self-care activities that further reduce symptoms.

From physiotherapy perspective, Johnston and Shaw (2013) noted in their work, that empowerment gives control to client, enables them to identify their problems and the intervention needed with the support of the physiotherapist and ultimately promotes independence Johnston & Shaw, 2013).

Finally, from nursing perspective, Munn (2010) defined patient empowerment as a process of giving hope, confidence and encouragement to people who feel disempowered by their health condition, ultimately promoting their well-being, decision making and self-management. Empowerment, therefore, improve the quality of life and the physiological conditions of the people empowered. Lawn et al. (2014) added that for there to be empowerment of client, nurse-client relationship must exist. They went further to say that the mere existence of the relationship is not enough for empowerment to take place, though.

There must be a balance of control, power and clarity of goals. Who controls what in the partnership between client and nurses plays a great role in client empowerment. They concluded that the overbearing control of nurses might put offclients with chronic conditions, who as a result of lack of mutual decision-making might feel powerless to engage actively in their own care.

The client must not be made to feel dependent, because as Lawn et al. (2014) opined, once a client has developed a dependency on the nurse, they become difficult to empower. Nurses asserting control over client hinders empowerment of client (Lawn et al, 2014), and from their study, client empowerment can only take place if nurses shared control during the process of caring.

Communication can negatively affect the empowerment process if the nurse overtly controls interaction without giving room for the client to express his/herself (Lawn et al., 2014). Blanchard et al. (2013) added that the more the amount and duration of community mobilisation engagement, the greater the empowerment levels.

Supporting Lawn et al. (2014), Cawley and McNamara (2011) added that empowerment is a relationship that a health practitioner tries to create with her client in order to help the client make better decision in achieving a healthier lifestyle and it is through the process of patient empowerment that relationships are built.

Again, supporting Cattaneo et al. (2014), Cawley & McNamara (2011) said that, though, public health nurses make attempt to form a nurse-client relationship, power still rest with the nurses and it must be shared.

Public health nursing is complex because the nurse is expected to empower and advocate for her clients whether to achieve health promotion, curative care or political advocacy (Cawley & McNamara, 2011). The practitioner is a facilitator (Cawley & McNamara, 2011; Johnston & Shaw, 2013), who is autonomous and empowered himself or herself too (Cawley & McNamara, 2011), and serve as guides in the process of empowerment with the optimal patient care being the goal (Johnston & Shaw, 2013).

Defining Attributes

Defining attributes are the characteristics of a concept that frequently appear when discussing the concept (Walker & Avant, 2011). From the interdisciplinary literature reviewed for this analysis, the four attributes of empowerment were proposed as follow; a practitioner-client relationship that is therapeutic (Bann et al., 2010; Cawley & McNamara, 2011; Kulik & Megidna, 2011;Lawn et al., 2014), a consensus decision making (Jones et al., 2013; Kulik & Megidna, 2011; Lawn et al., 2014), sharing of social power or giving a sense of control (Cattaneo et al., 2014; Kulik & Megidna, 2011; Lawn et al., 2014; Mehta & Sharma, 2011), and focusing on strength rather than weakness (Cattaneo et al., 2014).

Model Case

Nurse Tino, a Community Health Nurse, was recently employed and posted to Ofuoma community in Ughelli-North Local Govt. Area of Delta State, to head the health centre. On resumption, she was introduced to one of the community gatekeepers, Mrs. Emeteagbon, a woman leader, who took her round the community to introduce her to the influential people.

During these introductions, nurse Tino convened the need for them to plan for a formal gathering where the entire community will discuss and share ideas. After fixing the date and venue of the meeting, Mrs. Emeteagbon was asked to inform nurse Tino about it. On the day of the meeting, Nurse Tino introduced herself and her purpose of coming to the community. She encouraged the gathering to constitute a community development committee consisting of executives and members. Once the gathering finished choosing the committee, the chairman of the committee took charge of the proceedings of the meeting, with nurse Tino facilitating the discussion. They deliberated on the challenges facing the community, which include lack of pipe water, open drainages, open refuse, inadequate classroom blocks at the community school, and lack of proper market stores. With the help of Nurse Tino, they were able to set their short, intermediate and long term goals and determining the community resources available as being scarce they chose to tackle the issues of open drainages and refuse by tasking the youths and able body men to set a date to drain the drainages and bury and/or burn the refuse, while Mrs. Emeteagbon was chosen to organise refreshments for the workers, with the aid of the contribution to be made by the men of the community.

The above model case has all the defining attributes of empowerment. Nurse Tino was quick enough to make contact with some influential members of the community this led to the establishment of a therapeutic nurse-client relationship. Once the meeting was convened, nurse Tino suggested they constitute a committee and the gathering reached a consensus decision when they chose the committee. There was sharing of power - the community took charge of proceedings, while nurse Tino served as facilitator - a mutual feeling of control. She also focused on their strength by encouraging the community to tap from their resources thereby developing a sense of belonging.

Borderline Case

A non-governmental organisation earmarked a project for a community in the creeks of the Niger- Delta, on getting to the community, the NGO's focal persons met with some elders and asked them to plan for a meeting. During the meeting the focal persons chaired the deliberation, and asked the community members to highlight their problems in preferential order. The community listed their needs in the following order; classroom block at community secondary school, toilet facilities, pipe borne-water, electricity, community jetty and community town hall.

The focal persons asked the community members present to form a building committee and identify the resources available to the community that can contribute to the construction of the classroom blocks in addition to the NGO's resources. The focal persons took charge of the committee, directing them on what to do until the building was completed, launched and handed over the to the community.

The above case has some, but not all attributes of empowerment. While the focal persons tried to establish relationship, focus on the community strength and encouraged some mutual decision, they never showed any desire to share or transfer control to the community.

Contrary Case

Mrs. Otite, a 34-year-old woman, took her fiveyear- old son, Oghomena to Eku Community Health Centre with the history of acute watery diarrhea and severe dehydration of a day duration. After assessing the boy, Nurse Rhimena, the attending nurse collected stool specimen of the boy and sent to the laboratory. The result was positive for vibro cholerae, the causative organism of cholera. Further history taking revealed that Mrs. Otite is a widow, petty trader, with 5 children whose ages are between 3 to 12 years, they live in a single room, share a common pit latrine with their neighbors, and their source of drinking water is from the community stream. After completing the assessment and confirming the diagnosis of cholera, Nurse Rhimena placed the child on antibiotics of cotrimoxazole 36mg/kg/body weight for 3 days and oral rehydration therapy (ORT), and instructed her to avoid using water from the stream, and must continue to buy ORT sachets after the child has finished the one she gave her.

No element of empowerment was present in the above contrary case. The nurse used a paternalistic approach to address the presenting problem. She ignored the fact that the woman is a widow and poor, and did not give room for her opinion about the problem, the nurse just laid down the solutions she wanted her to take irrespective of whether the woman is equipped to execute them or not.

Antecedents and Consequences

Avant and Walker (2011) stated that antecedents are the events that precede the occurrence of the concept. Four antecedents of empowerment were identified from the literature; they are social motivation, availability of information or choices, participation by all parties and willingness to share power with others. The following are the consequences of empowerment; social justice (Cattaneo et al., 2014), independence (Johnston & Shaw, 2013; Lawn et al., 2014), confidence (Munn, 2010).

Empirical Referents

Many instruments exist that are used to measure client empowerment, though there is no general agreement on how best to measure it because these instruments have been independently fashioned for specific conditions. Some examples include; the Empowerment Scale that is used for mental health, the Diabetes Empowerment Scale for diabetics, the Patient Empowerment Scale for cancer clients (Bravo, et al., 2015).

Operational Definition

After analysing the various disciplines literature on empowerment, an operational definition of client empowerment is hereby proposed:

Client empowerment is a process by which the community health nurse and her client institute a therapeutic relationship within a supportive social climate characterised by respect, mutual decisionmaking, and power sharing leading to client independence, increased confidence, self-reliance, and self-management.

Limitations

The literature review used for this analysis was restrictive because; (1) articles were searched using the words client and empowerment, (2) articles published within 2010 to 2015, and (3) this analysis was influenced by the desire to analyse client empowerment in community health nursing context.

Summary

Various meaning has been given to empowerment by different professionals from different fields of endeavors. From a nursing source that termed it as the giving of hope, confidence and encouragement to client Munn (2010), to physiotherapy, management, women development, community psychology and marketing, that clarified it as to give control or to share power (Cattaneo et al., 2014; Fuchs et al., 2010; Johnston & Shaw, 2013; Mehta & Sharma, 2014).

Conclusion

The raison d'être of this concept analysis was to delve into literature on empowerment from a range of disciplines and propose an operational definition of client empowerment in community health practice through the use of generated attributes, antecedents and consequences of client empowerment. This was done in a limited way as briefly described above.

Client empowerment will facilitate the practice of community health nursing; improve client confidence and satisfaction of health services rendered by nurses. This analysis can be expanded by additional analysis to gain new understanding of the concept, thereby adding to the body of nursing knowledge.

References

References

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Bann, C. M., Sirois, F. M., & Walsh, E. G. (2010). Provider Support in Complementary and Alternative Medicine: Exploring the Role of Patient Empowerment. Journal of Alternative & Complementary Medicine, 16(7), 745-752.

Blanchard, A. K., Lakkappa, M. H., Shahmanesh, M., Prakash, R., Isac, S., Ramesh BM, Bhattacharjee P, Gurnani V, Moses S, & Blanchard, J. F. (2013). Community mobilization, empowerment and HIV prevention among female sex workers in south India. BMC Public Health, 13(1), 1-13.

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empowerment. (n.d.). Dictionary.com Unabridged. Retrieved October 07, 2015, from Dictionary.com website: http://dictionary.reference.com/browse/empowerme nt empowerment. (n.d.). Roget's 21st Century Thesaurus, Third Edition. Retrieved October 07, 2015, from Thesaurus.com website: http://www.thesaurus.com/browse/empowerment

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