ClinicalSelf-empowermentinhealthpromotion: a realistictarget?NiciMackintoshTherehave heenmanycalls fornursesto adopt aself-empowermentmodel forhealthpromotionpracticeratherthancontinuingto workfromthe medicalmodel. Continuingwithour series onhealthpromotion,this article examinesfeaturesof theself-empowermentapproachandquestionswhetherits goals areachievahle.TJLh(Nici Mackintoshis SeniorClinicalNurseat SandwellHealthcareNHSTrust,WestMidlands4lhheterm'healthpromotion'is'verydifficulttopindownfordescriptivepur-poses'(Beattie,1991).Inthisarticle,it isaccepted that health promotion includes:'...both health education and all attemptsto produce environmental and legislativechangeconducivetogoodhealth'(Dennis et al,1982).While healthpromotioninvolves the alter-nativeandcomplementaryprocessesofsocialengineeringandhealtheducation,thelatterisaboutfacilitatinghealthchoices:'Healtheducationisconcernedwithraisingindividuals'competenceandknowledgeabouthealthandillness,aboutthebody anditsfunctions,aboutpreventionandcoping;withraisingcompetenceandknowledgetousethehealth-care system and to understand itsfunctions;andwithraisingawarenessabout social, political and environmentalfactorsthatinfluencehealth*(Baric, 1985).StrategiesforhealtheducationHealtheducationtakesdifferentapproaches.Inanefforttoexaminethepracticalimplicationsandgoalsforeachstrategy,manyauthorshaveattemptedtodeviseclassificationsfortheseapproaches(e.g.Tones.1981,1986;Beattie,1982,1991).Fiveclassificationsforsuchapproaches can be identified{Table 1).Researchstudies(Johnston,1988; Latteretal,1992; Mackintosh,1993)havecon-firmedthatthemajorityofnursespersistwiththebehaviouralchangeapproach.Gottand O'Brien(1990) place responsibil-ity forthis situationonindividualistic ide-ologiesandlimitedhealthpromotionprogrammesandpoliciesforhealthinnursingwhichemphasiseframeworksofindividualisticactionat the expense of col-lective nursing philosophies.Criticsofthebehaviouralchangemodelpointoutthatitassumesthatlaypeoplebelieve the 'experts' know best. The modelimposesmedicalvaluesontheindividualand may also impose feelingsof guilt if theclientchoosesnortofollowtheregime.Moreover,intermsofaviolationofrespectfortheindividual'sautonomy,thereareethicalobjectionstoitsassump-tionthatprofessionalshavetherighttodecidewhatconstitutes'healthybehaviour'.Boththebehaviouralchangeandeduca-tionalapproachesembracetheexistentialbelief that;'Peoplearebornfreeandcreatethemselvesbymeansoftheirdecisionsand choices' (Jacob,1994).Individualsare perceivedas freeto choosea courseofactionandarethereforecon-sideredresponsiblefortheirhealth.Thisindividualisticconceptofhealthhasbeenstronglycriticizedasitfailstotakeade-quateaccountofthesocialandeconomicdeterminantsofill-healthandhealth-relatedbehaviouroutsideanindividual'scontrol.The socialactionapproachviews humannaturefromthedeterministperspective.Deterministsbelievethata person'sfree-dom is limitedby biological, psychologicalandsocialforces. Thesecause factorssuchas race, gender, socialclass andgenetics tobecomethedeterminantsofhealth.Thisstrategynotonlyaddresses thefundamen-talsocialissuesunderlyingdisadvantageandill-health,butalsocanberegardedascoercive forit seeks to perpetuatea partic-ularpoliticalviewofsociety(Tones,1986).Furthermore,itseemsnaivetoplacetotalresponsibilityforhealthon the state.Whereas the governmenthas a dutyto cre-atefacilitiesforhealth,itisstilluptotheindividualtoactuponinformationin aBritish Journalof Nursing,1995. Vol 4, No 211273Self-empowermentin healthpromotion: a realistictarget?TableI. Strategic approaches for health educationBehaviour change (preventiveor traditional approach)Focus: the individualEducational approachSocial action, radical, socialchange approachSelf-empowerment,humanistic approachCommunitydevelopmentapproachGoal: to persuade the individual to adopt a particularlifestyle/adhere tomedical advice to prevent/limitdisease and reduce mortality/morbidityratesRationale: curativemedicine cannot cope withcurrentrate of disease.Preventionbetter/cheaperthancureEvaluation: measured on whetheror not the individual adopts a particularlifestyle or changes his/herbehaviourExample: advising/persuading the individual to give up smokingFocus: the individualGoal: to help the individualdevelop his/herknowledge and skills andexplorehis/herattitudes, so that he/she can make an informed choice abouthis/her healthRationale: education is about rationalityand freedom of choiceEvaluation: measured on the facilitation of decision-making, irrespective ofthe nature of the decision actually madeExample; presenting the individual with the facts about smoking and leavingtheindividual to make a choiceFocus: the environment at societal levelGoal: to make healthy choices the easy choices by changing the physicaland social environment so that individuals are enabled to adopthealthybehaviour. Also aim to raise individuals' awareness and involvement in healthissues in orderto stimulate the demand for social changeRationale: the root of health problemslies in social, economicand politicalfactorsEvaluation: measured on the implementation of critical consciousness-raising, and/orsocial, political or environmentalchange conducive to healthExample: campaigning for smoke-free areas, lobbying parliament for anadvertising ban on tobaccoFocus: the individualGoal: to facilitatedecision-making by modifying the individual'sself-concept and enhancing self-esteemRationale: by developing motivation, setf-confidence and skills, theindividual is in a betterposition to identifyhis/her own health needs and takeaction to meet themEvaluation: measured on the acquisition of life skills and decision-makingskillsExample: enabling the individual to identify why he/she smokes, helping theindividual to develop the confidence and skillsneeded to make a choice andimplement a health planFocus: a groupGoal: to help a group worktogether, find its commoninterests andfight its particularhealth causeRationale: it is betterto workfrom the group's valuable experiencesrather than to workfrom a professionallydefined agendaEvaluation: measured by successful public awareness raising of the group'sconcernsand the implementation of health action for the benefit of the groupExample: identifying a need for a self-help group, facilitating the group, actingas resource and supporterfor the group1274Brlti5h Journal of Nursing, 1995, Vol 4. No 21Self-empowermentin health promotion: a realistictarget?^Within thehospital setting itis oftenmuchharder toempower theindividualbecause of thenature of theinstitution itself.However^ on asmaller scale, thenature of personalinteractionsbetween nurseand patientcanplay an importantpart.'waythathe/shethinksbest.Asocialactionstrategymay failtoprovidetheindividualwiththe motivationto internal-izethe valuesitpromotesortopromoteautonomousself-care.Anapproachinvolvingthe pursuitofself-empowermentfacilitatesinformedchoiceswhichare so hardto achieve withtheeducationalapproach.Aself-empow-erment strategy aims to:PromotebeliefsandattitudesfavourabletodeferringimmediaterewardformoresubstantialfuturebenefitIncreaseinternalcontrolandself-esteemanddevelopsocialskills,e.g. assertiveness (Tones,1981)Thus,the onusis on the individual, butbecausethe self-empowermentstrategyaimstohelplearnersbecomemoreself-assertive,tbe individualis able todevelopanotionofbeingincontrol.Aself-empoweredpersonis betterableto resistpressurestosmoke(Tones,1986) andhasmoreunderstandingandcontroloversocial, economic and political forces.Thecommunitydevelopmentapproachshares many featuresof theself-empower-mentapproach,but it is on a larger scale.Whereasthe self-empowermentapproachislimitedtodevelopingtheindividual'sabilitytodealwithsocialinjustices,thecommunitydevelopmentapproachallowscertaingroupstoworktogethertofightfortheir health needs.*If nursingis to take healthpromotionseriouslyit mustbe activelyconcernedwiththe empowermentof clients andpatients' (Tones,1993).Recognitionof the criticismslevelled atthebehaviouralchangemodel,togetherwithrecentinterestinholisticand client-centrednursing,has resultedin a changeoffocusinhealthpromotioninnursingtowards the theory ofself-empowerment.Theory ofself-empowermentThere are fourfactorswhichTones (1993)considerscentraltotheconceptofempoweredaction for the individual:1. Theenvironmentalcircumstanceswhichmay eitherfacilitatethe exerciseof controlor, conversely, presenta bar-rier to freeaction2.The extent to which individuals actuallypossesscompetenciesandskillswhichenablethemto controlsomeaspects oftheirlives, and perhapsovercomeenvi-ronmental barriers3.The extentto wbichindividualsbelievethemselves to be in control4.Various emotionalstates or traits whichtypicallyaccompanydifferentbeliefsaboutcontrol suchasfeelingsofhelplessnessand depression,orfeelingsofself-worth.Oneof the criticismsagainstthe educa-tionalapproachisthatthemereunder-standing of a healthissue is not enough toprecipitatehealthaction. The provision ofinformationneedstobe accompaniedbyprocessesof beliefand the clarificationofvalues, followedby some practicein deci-sion-making usuallyin a simulated set-ting.For self-empowermenttooccur, adevelopmentalprogrammeisrequired,aimedatcertainaspectsofpersonalgrowth.Two importantpersonalitychar-acteristicscentraltothisprocessare self-esteem and locus of control (Tones, 1986).Self-empowermentin practiceManynursesconcernedwithcommunitydevelopmentare involvedinempoweringboth individuals and groups. The agenda isfrequentlyset byindividualswithinthecommunityratherthanby the profession-als, and the role of the nurse is not that ofanexpert,but of a facilitatorand partner.Forexample,theschoolnursemayrespondtoteenagers'requeststorun aworkshopon copingwiththe problem ofpeer pressure to experimentwithdrugs, orapracticenursemay set upaself-helpgroupto helpindividualsdealwithstress.Igoe(1993)andWalker(1993)providefurtherexamplesofcommunitysettingswiththe potentialforself-empowermentstrategies.Withinthehospitalsettingitisoftenmuchhardertoempowertheindividualbecauseofthenatureoftheinstitutionitself.However,on a smallerscale, thenatureofpersonalinteractionsbetweennurseand patientcan playanimportantpart. By respectingthe individual'swishesandallowingthepatienttherighttochoose,the likelihoodofdisempoweringthemdividualis minimized.Believing thatonehas somekindofcontroloverone'slifeisbeneficialinmanyways(Tones,1993). However,merelyhavingthe beliefthatone is in control is not generallysuffi-cientfortheempowermentprocesstobegin;theindividualmustalsobe pro-videdwiththecompetenciesneededtoachieve his/her goals.Wilson-Barnett(1993)notedthatenabling people to maximize theirindivid-British Journal o( Nursing,1995. Vol 4, No 211275Self-empowermentinhealthpromotion: a realistictarget?Howmanynurses are in apositionto giveadequatequalitytimeandprivacy,in a suitableerivironmentytoenable thepersonaldevelopmentof apatieritfNursesofteii take on tberole of Jianiednurse for anumber ofpatientsand areunable, due tolack of contacttime,to buildupthe deptb ofrelationshipnecessary todeveloppatients'life-skills andpotentialformanagingtbeirownhealth.ualpotentialshouldbetheaimofmany.\j;encies(statutoryandvoluntary)and'healthprofessionalsmaybeinaspecialsituationloinfluencethis'.Butarenursesina positiontofacilitatepatients'personalj^rowth? In order to examine this question,thelocationoftheempowermentprocesswithmthecontextofthecounselhngrela-tionship must be established.Person-centredcounsellingItis possibletodrawa parallelconclusionbetweencertaincharacteristicsoftheper-son-centredcounselling relationshipof theclientandcounsellorandtherelationshipestablishedina self-empowermentstrat-egy.Person-centredcounsellingplaceshighvalueontheindividual'sexperiencesandtheimportanceoftheindividual'ssubjectiveperceptionsofreality.Itchal-lenges each personto acceptresponsibilityforhis/herownlife,andtotrustthe irmerresourcesavailabletoallthosewhoarepreparedtodevelopself-awarenessandself-acceptance.Thenotionsofself-empowermentandperson-centredcounsellingbothfitintothecategoryofa 'helpingrelationship*, asdefinedby Rogers (1967):'A helping relationship is one in which atleast one of thepartieshas the intent ofpromotingthegrowth,development,maturity,improvedfutictioning,andimproved coping with life of the other.'Theyalsoemphasizetheimportanceofunleashingthepowerthatlieswithintheindividualratherthanrelyingontheauthorityof the expert.Table 2. People involved inhealthpromotionTown-plannersAgriculturalistsIndustrialistsandbusinessmenPoliticiansThoseinvolvedwithcommunicationandmassmediaEnvironmentalhealthworkersDirectorsof transportservicesEducationalistsandsocialworkersMedicalandheatth-careprofessionalsSource: Tones (1966)Itthereforefollowsthatmanyoftheconditionsnecessaryforthedevelopmentofatherapeuticrelationshipbetweencounsellorandclientmay also be requiredtofosteragrowth-conduciveclimatebetweenpatientandhealth-promoter.However,oncloserexamination,theful-filmentoftheseconditionsislikelytobeseenasproblematicwithincertainfieldsof nursing.First, howmanynursesare in a positionto:Be genuine?Offerunconditionalpositiveregard andtotalacceptance?Feelandcommunicatea deepempathicunderstanding towards the patient?Yet the counsellormust demonstrate thesequalitiesinordertofacilitatethepersonalgrowthof the client (Rogers, 1967).Second, the client voluntarilychoosestoforma relationshipwiththecounsellor.Thepatient,ontheotherhand,isoftenforcedtoformsomekindofrelationshipwith the nurse. There is still the element ofchoiceastowhatformthisrelationshipshouldtake, buthe/she maymay not wishtotakeresponsibilityforhis/herown health.Howmanynursesareina positiontogive adequatequalitytimeandprivacy, ina suitableenvironment,toenabletheper-sonaldevelopmentofapatient?Nursesoftentake on the role of namednurse for anumberofpatientsandare unable, duetolack ofcontacttime, tobuildupthe depthofrelationshipnecessarytodeveloppatients'life-skillsandpotentialforman-aging their own healthThus, we need to question thefeasibilityofsettingself-empowermentasa goalfornursingpractice.Itisquestionablewhetherthemajorityofnursesareinasufficientlycredibleandempoweredposi-tionthemselves tobe able to facilitate self-discoveryinothers.Howmanynurseshaveaccesstosupportnetworksandopportunitiesforguidancefromqualifiedexpertsto dealwithemotionallythreaten-mg situations?Thereis an additionalproblemforthosenursesworkingwithinthehospitalstruc-ture.Themanagementofhealthandwel-fareissues has traditionallybeenplacedinthehandsofexperts,locatedwithinlarge,centralizedbureaucracies.Ina systemthatcallsfordominancebyprofessionals,it isdifficulttoachieveegalitarianworkingrelationships.A callforactivelyparticipa-tiverolesforpatientschallengestheexist-1276BritishJournalofNursing.1995. Vol 4, No 21Self-empowermentin healthpromotion: a realistictarget?ingpower/controlbase(Kcyzcr,1988).Thereistheaddeddangerthat,inanattempttoadoptafacilitativeapproach,activitieswhicharc,inreality,manipula-tive anddefinedbythenurse'sagenda canbe labelledas participative.Similarly, many of the measures for eval-uationofhealthpromotionsuccesswithinbothcommunityandhospitalset-tings are still definedby the behaviouralchangeapproach.Itishardfornursestowork within a model ofself-empowermentwhentheirworkisoftenevaluatedbycomplianceratesandevidenceof'positive'changesinlifestyle(Mackintosh,1996).Thereisalsoa dangerthatnurseswillfocusonthosepatientswhoarereceptivetoandateasewiththenotionoftakingcontrolforthemselves.Thesepatientsarelikelytobeinthehighersocialclasses. Ineffect,thisactuallyperpetuatessocialinequalityandmaintainsthestatus quo:'...thegreatestbeneficiariesbeing thosewhoarealreadywellabletocaterfortheirownhealthneeds, andwho havethe power and social influenceto changethingsfurthertotheirown advantage'(Campbell, 1993).The definitionof self-empowermentalsoinvolves the facilitationof some exercise ofcontrolovertheenvironment.Itis ques-tionable how many nurses are in a positionto do this.KEYPOINTSThere are threeindividualistichealth educationapproaches:behaviour change; educational; and self-empowerment.Traditionally, the focus in health education in nursing hasbeen one of behavioural change.More recently, many authors have advocated a move towardsa self-empowermentapproach for nursing.Due to the constraints of the working environment andnurses' lack of skills, it is often unrealisticto expect themajority of nurses to be in a position to empower andfaciiitate the personal growth of a patient.It is important to acknowledge that nurses are in an importantposition as providers of information, not as indoctrinators oradvisors, but as carers.Nurses have a duty to acknowledge the social structural facetof health.SettingnewtargetsItis importantnottolose sightofthe. factthatthelistofthoseinvolvedinhealthpromotionisextensive{Table 2). Onceitisacknowledgedthathealthprofessionalsactuallyplayarelativelymarginalroleinhealth promotionwithin the wider contextofpublichealth,itmaybeeasierfornursestore-cvaluatetheaimsoftheirpractice. After all:'Healthpromotionmustuseawidevarietyofcomplementarystrategies'(World Health Organization, 1984).All healtheducationstrategiesshouldberecognizedashavingtheirowndegreeofimportance, sincehealthcanonlybe pro-motedin societywhenan amalgamofdif-ferentapproaches are applied.Therefore,the aims ofhealthpromotionpractice fornurses should be:Tostriveforunconditionalacceptanceof the health values of individualsToshowconsiderationoftheenviron-mentalandsocialfactorsaffectingindividualsTo offerhealth informationwhich shouldnottaketheformofindoctrination,advice, or persuasion.Nursesneedtobeaware thatit is almostimpossibleto giveinformationthat is totally devoid of valuejudgments. Thus, nurses needto developtheircommunicationskillsandexaminetheir position as providers of information.Healthpromotionpracticefornursesshould thereforetake the formof:ValuingindividualsandtheirhealthbeliefsShowing sensitivitytotheenvironmen-tal,socialandeconomicfactorsaffect-ing the health status of individualsProviding healthinformationConstantlyevaluatingandreviewingtheaccuracyofavailablehealthinfor-mationRaisingindividuals'awarenessofthesocial,economicandenvironmentaldeterminantsof healthInformingindividualsoftheirrights,and how to access other servicesInvolvingindividualsindecision-mak-ing wheneverpossibleOfferingsupporttoindividualsbymobilizingappropriateresourcesandliaising with appropriateprofessionalsRespectingindividuals'rights tochoosetheir own courses of action forhealthUnitingwithothernursestoensurethatprofessionalbodieslobbyforgoodpublic health poUcies.BritishJournalof Nursing.1995, Vol 4, No 211277Self-enipowerinentin health promotion: a realistic target?ConclusionWhereasthosenurseswho are in a posi-tiontofacilitatepersonalgrowthinpatientsshouldbe encouragedto do so, itis importantnot to excludethose who arenot.Therefore,allnursesshouldbeencouragedto assesstheirrolesas carers,andtoreviewtheirrelationshipswithpatientsfromtheperspectiveoftheirpotentiallypowerfulpositionsas healthprofessionalsand information-givers.Inthis way, nurses can use approaches whichtakenote of socialstructurefactorswhilefocusingon individuals'needsand theirpersonal resources.Baric L (1985) The meaning of words: healthpromo-t i on. ;InstHealthEdHc2ii\):367-72Beattie A (1982)ChangmgCodes of Health.SeminarNotes.InstituteofEducation,UniversityofLondonBeattieA(1991)Knowledgeand controlinhealthpromotion:a testcaseforsocialpolicyand socialtheory.In: Gabe J,CalnanM, BuryM. eds.TheSociologyoftheHealthService.Routledge,London:162-202Dennis J, DraperP, HollandS, ShipsterP, Speller VandSuntcrI(1982)HealthPromotionintheReorganisedNHS.UnitforStudyofHealthPolicy,LondonCampbellA (1993)The ethicsofhealtheducation.In:Wilson-BarnettJ,Macleod-ClarkJ,eds.ResearchinHealthPromotionandNursing.MacmillanPress, Hampshire: 2-8GottM, O'BrienM (1990) The role of the nurse inhealthpromotion.HealthPromotionInt 5(2):3 7 3Igoe J(1993)Healthierchildrenthroughempower-ment.In: Wilson-BarnettJ, Macleod-ClarkJ,eds.ResearchinHealthPromotionandNursing.Macmillan Press, Hampshire:145-53JacobF (1994)Ethicsinhealthpromotion:freedomor determinism?BrJ Nurs3(6): 299-302JohnstonI(1988)Astudyofthepromotionofhealthylifestylesbyhospitalbasedstaff.UnpublishedMScthesis,UniversityofBirminghamKeyZL-rD(1988)Challengingroleboundaries: con-ceptualframeworksfor understandingthe conflictarisingfromthe implementationot t henursingprocessin practice.In: White R, ed. Political IssuesinNursing:Past, Present and Future.Vol 3. WileyandSons, Chichester,95-119LatterS, Macleod-Clark J, Wiison-Barnett J, Mabin J(1992)Healtheducationin nursing: perceptions ofpractice in acute settings./-4(/i;M