Chapter 13. Empowering Partnerships
Nurses and Those They Care For
Kristine Martin-McDonald
This chapter:
■ explores the traditional roles of nurses and those they care for;
■ discusses the concepts of empowerment and partnerships as they apply to the provision of health care;
■ examines the key concepts of a partnership model:
a) non-patronising empowerment;
b) collaborative decision making;
c) valuing diversity and individuality; and
d) mutually beneficial relationship; and
■ identifies the threat to each characteristic of the partnership model.
In this, the final chapter of this text, we discuss how nurses can effectively form healing partnerships with those they care for. Once nurses are able to appreciate the broad range of issues surrounding the illness experience, they can then consider approaches to working in partnership with their patients, aimed at enhancing the health and wellbeing of these patients. This chapter briefly examines the traditional roles of nurses and patients, before considering the characteristics of an empowering relationship, built on partnership. This kind of relationship requires a commitment to the notion that people who are ill and in need of health care should be in charge of their own care, with nurses working with them rather than taking control. The specific elements of partnership models—non-patronising empowerment, collaborative decisions and mutually beneficial outcomes—are discussed as well as the threats to each of the elements being implemented. Throughout this chapter a case study is presented to highlight the main points raised.
The notion of the sick patient as helpless, passive and reliant on the advice of health care professionals has been extensively challenged. In its stead is an approach that acknowledges the need for active involvement of patients in their care as well as in the development, implementation and evaluation of health policies and systems. The recipients of health care are increasingly seen as consumers, a move which is accompanied by a greater focus on patient rights (Germov 1999). Individuals are encouraged to take greater responsibility for their health and wellbeing, and easier access to health information means that the recipients of health care are often very well informed about their illness. As a result there has been a significant move to ensure a collaborative effort is fostered between the key stakeholders in the provision of health care, namely users of health services and the health professionals caring for them.
Evolution of caring for the unwell
The most common term for the people that health professionals care for is ‘patient’. ‘Patient’ has its origin in the Latin terms patiens and pati which means ‘to suffer’, ‘one who suffers’. It is also used to define ‘one that is actuated upon or undergoes an action’ and ‘one who receives medical attention, care or treatment’ (Oxford Dictionary 2003). Historically the term ‘patient’ was associated with the sick role that Parsons (1950) described as legitimising a person’s temporary exemption from normal social responsibilities whilst ill. Four assumptions underpinned this sick role:
1. The patient is exempt from usual roles and responsibilities.
2. The patient is not responsible for his or her incapacity (illness).
3. The patient is willing to get better (desire to leave this state of temporary incapacity or social deviance).
4. The patient is obliged to seek expert help and to cooperate with treatment regimes.
This designated sick role description has been criticised (Nyatanga & Dann 2002, Watt 2000). In these times there is more of an acceptance of diversity, blurring of role boundaries and an acknowledgment that individuals are unique. Those who are cared for by nurses are well positioned to know, understand and decide what is best in their life situation. If this is the case, then it would seem appropriate that each person ought to have the freedom to choose their behavioural options rather than be expected to conform to prescribed sick role behaviour.
Jim is an active and healthy 67-year-old man who has been struggling to cope for a couple of years since the death of his wife. He explains to his son (Peter) that he has lost his ‘zest’ for life since then, and really has trouble getting interested in anything.
| J: | I just can’t be bothered, you know. Everything seems like too much of an effort. |
| P: | Have you seen anyone about this Dad? |
| J: | No! I’m not going to get treated like some mad idiot. |
| P: | But Dad, perhaps you need some help in managing how you’re feeling right now. This problem won’t disappear. There are some great nurses at the Community Mental Health Clinic. I know someone who went there for help, and she said it was great. Her nurse really listened to her, and asked her how she wanted to manage the problem. |
| J: | You mean a nurse might be interested in my opinion? The nurses in my day just told you what to do! |
| P: | Things have changed a lot in the last twenty years Dad. |
| J: | Yeah all right. I guess I’ve got nothing to lose. |
Even the term ‘patient’ has been challenged as being inappropriate language for health care uses. The label ‘patient’ allows a mindset that renders the health professional superior to and in control of their patients (Nyatanga & Dann 2002). It is this traditional positioning of nurses that, if adopted, gives them significant control over their patients. In Jim’s case, his previous experience with nurses was that they were always in the dominant position, and liked to keep things that way. Within this traditional model of nurse and patient, there can be some unfortunate consequences for ‘patients’ who ask questions, challenge the authority of the professionals or seek some control over the decisions related to their care. They might find that they are labelled as difficult and could be alienated for such behaviour. Some of the characteristics of both the nurse and the patient in this traditional model are identified in Table 1.
| TRADITIONAL MODEL OF HEALTH CARE | |
|---|---|
| NURSE | PATIENT |
| Powerful | Powerless |
| Expert | Lay person |
| Prescribed care | Passive recipient |
| Language authoritative | Language accepting, respectful |
| Authoritative knowledge, training, skills in health matters | Lacks knowledge, skill in health matters |
| Narrow focus on care of disease or illness | Focus on getting well |
| Emotionally distant | Emotions kept in check |
This imbalance of power is problematic in relationships between nurses and health care users, particularly in relation to those who are chronically ill. Unlike acute illness, chronic illness by its definition is long-lasting. Whilst there is a diagnosis and treatment regimes, the tolerance of being exempted from social responsibilities, such as those given to people with acute illnesses, is short-lived for those with chronic illnesses. Chronic illnesses are managed rather than cured, may deteriorate over time, are often accompanied by additional diagnoses of other chronic illnesses, are unpredictable and diverse in their presentation in each person (Watt 2000). The focus in chronic illness is on delaying the progress of the disease, minimising acute exacerbations associated with the illness and maintaining optimal functioning for the individual for as long as is possible. Thus people with chronic illnesses are required to be self-managing, self-monitoring and largely self-treating.
Often those with chronic illness feel ‘invisible’ in the social world, particularly if they manage their illnesses well. This invisibility fails to validate the intrusiveness of the illness in all aspects of their lives and their families, and the need for constant vigilance and adaptation to the deterioration in the health of the sufferer. The changing face of the chronic illnesses continually challenges their image of who they are and what their place in the world is. The sick role fails to capture the experience of those living with chronic illness and the roles of their nurses (Watt 2000, p 14):
In chronic conditions, providers normally hold little in the way of unique expertise and no curative ability. Therefore clinical decision-making is focused on disease management and the patient is not only empowered, but also often required, to take an active and central role in this process
Empowerment
Despite improved medical technologies and long-term survivorship of chronic illnesses, modern medicine is heavily critiqued as being all-knowing and all-powerful as well as for its high costs (Germov 1999). The traditional roles of both nurses and those they care for continue to exist in health care settings, and in this context nurses might, wittingly or unwittingly, adopt ways of relating to those in their care which are intimidating to them. The hierarchical structure of many health care institutions and disciplines, supported through the use of the sick role model, is perhaps the most significant obstacle to empowered partnerships. Nyatanga & Dann (2000, p 237) hold a strong view that:
As long as service users are referred to as patients and are expected to comply with the sick role then empowerment will remain an ideal that will never be realized.
Empowerment has Latin root origin in the word power, potere, which means ‘to be able’. Its prefix ‘em’ means ‘cause to be or provide with’ (Oxford Dictionary 2003). Empowerment is seen as beneficial to the health of a person because it involves enhancing a person’s capacity to influence or control significant aspects of their lives. Helping someone to be more empowered is about helping that person to develop the personal resources necessary to manage their own situation, rather than doing everything for them.
Empowerment requires recognition that both nurses and those they care for have expertise, which may differ in content and context but which, when assimilated, can be complementary. This has the potential to bring about the best health outcomes. Thus, if empowerment is to occur, nurses need to move out of their frame of reference as the expert. This does not imply that their expertise is not required or is obsolete, but rather requires a partnership approach where both nurses and users of their services come together for the benefit of the user.
Empowerment of patients has been advocated by the World Health Organization since 1986 (Houston & Cowley 2002) yet it remains somewhat elusive in health care settings (Tanner 1998, Ryles 1999). It has been argued that ‘the acknowledged chink between ideals of user empowerment and realities of everyday practice is in fact a yawning chasm’ (Tanner 1998, p 447) and that the ‘subservient and deferential culture’ of nursing (Ryles 1999, p 602) has created an unwillingness or inability to embrace empowerment.
Jim made an appointment with a mental health nurse at the clinic. Following the visit Jim and Peter talk.
| P: | So how was it? |
| J: | You know he was really nice. He listened to me, and then talked about some different ways that we could work on the problem together. I really liked that. He says he thinks I’m depressed. He didn’t use any of that fancy medical language, so I understood everything. He didn’t push me to do what he thought was best either. |
| P. | So what are you going to do? |
| J. | I’m going back next week. The nurse says I can’t expect to get better quickly, and he reckons it might be good if I also saw the psychiatrist at the clinic, to see if medication would help. I’m not sure about that one though. I’ll stick with the nurse for now. It feels better just talking about things with him. |
| P: | Sounds good Dad. |
Strategies for developing empowering partnerships with those we care for will differ according to the particular needs of each person. In Chapter 6, Multicultural Issues in Health, we are reminded of the enormous cultural differences in the perception of health and illness, and how important it is to ask those we care for to tell us about their cultural practices and beliefs. This is an important first strategy in ensuring culturally safe care. Consider also those from low socioeconomic status (SES) groups. Chapter 3, Class, Poverty and Chronic Illness—Intersecting Links, identifies that a key fact relevant to the poor health of lower SES workers is that they experience little control in their lives. With such a background it may be that these people bring an expectation that they will have no choice or say in their health care. Establishing empowering partnerships between nurses and disadvantaged or vulnerable minority groups may take time, special consideration and sensitivity to issues relevant to such groups.
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