Empowerment in today’s NHS

The term “empowerment” has been used and abused for many years, with some practitioners believing it to be “old hat”. In addition, definitions of empowerment vary, adding confusion regarding what it is and how it can be achieved. However, it is increasingly being highlighted in national NHS policy, and it is therefore worth revisiting, particularly in terms of how nurses can practically achieve this in their work with people with diabetes.

Anderson and Funnell (2005) provide a good working definition of empowerment as “helping people discover and use their innate ability to gain mastery over their diabetes”. The following elements contribute to the overriding philosophy of empowerment:

• People with diabetes are autonomous.
• The choices they make in their day-to-day lives have the greatest impact on their diabetes control and quality of life.
• Healthcare professionals need to work alongside people with diabetes to explore their concerns and their experiences of living with the condition and to help people identify and achieve their own goals.

It can feel uncomfortable not being “in charge” when encouraging people with diabetes to be involved in the decision-making, yet empowerment does not require healthcare professionals to give up control, but to give up the illusion of being in control (Anderson and Funnell, 2000). It is also a common belief that the person’s behaviour is the problem that requires attention, whereas in reality, their behaviour is simply a symptom of their underlying thoughts, feelings and beliefs. By exploring the world people inhabit and what they personally want to achieve, nurses are much more likely to have a positive influence on their behaviour (NHS Diabetes, 2008).

How does empowerment fit in with NHS policy?
In a recent review of the evidence on self-management, de Silva (2011) identified over 550 pieces of high-quality research and concluded that it is an effective strategy, not only for individuals, but also in the use of healthcare resources. National policies recommend that individuals take responsibility for their own health (Department of Health [DH], 1999); are listened to rather than talked at (DH, 2000); have more say in their treatment (DH, 2004); and that “no decision about me, without me” becomes the norm (DH, 2010). In addition, there is recognition that for healthcare professionals new skills will be required (DH, 2006); skills-based training should be accessible (Diabetes UK, 2009); and for some it will require a “significant cultural shift” in their thinking and behaviour (DH, 2009). 

Where are we now? 
Empowerment techniques are being incorporated into all the national group education programmes such as X-PERT (Deakin et al, 2006). There is also evidence of empowerment being put into practice in individual consultations (Sturt et al, 2008). However, although many nurses believe this is the way forward and may be inspired to change their practice, it can be difficult to avoid the temptation to offer solutions to people with diabetes. Tools and strategies (Anderson and Funnell, 2005) and skills training (www.successfuldiabetes.com) to further develop and support implementation of the empowerment approach are available.

For nurses wishing to implement the empowerment approach, the first step is to identify what beliefs and values they hold about working with people with diabetes. The following questions can be useful:

• Should people with diabetes make more decisions about their lives?
• Will the decisions they make have more impact than the ones nurses make?
• Are individuals capable of making decisions that will benefit their health?

Answering “yes” to all three questions demonstrates beliefs that are in line with the philosophy of empowerment. Therefore, the next step is to try putting it into practice. There are a number of techniques that can be used to experiment with the empowerment approach during consultations, and focusing on one of these can be a useful starting point:

• Make individuals with diabetes aware that their thoughts, feelings and experiences are valued.
• Share health results with individuals, together with an explanation of their meaning, before their consultation.
• Encourage individuals to explore their own thoughts and ideas about their diabetes.
• Identify your preconceived ideas and potential solutions before the consultation and put them aside.
• Elicit concerns of the person with diabetes by asking an open question at the beginning of the consultation and allow them to respond without interruption.
• Actively listen to the individual by displaying encouraging body language.
• Focus on the issues that people express themselves for the entire time of consultation.
• Avoid giving advice or sharing your own solutions to their problems or concerns.
• Assist people in working out what they most want to achieve (their goals) and what they can do to get there (their action plan).

Conclusion
There are no rules for diabetes self-management, only choices that have consequences. Implementation of national policy using an empowerment approach enables nurses to engage with people with diabetes in an effective manner, allowing them to recognise their choices and consequences and take responsibility for their condition, which can lead to improved health and quality of life.