Patient empowerment

Patient empowerment refers to a process where people gain greater control over decisions affecting their health. The principle is to enable patients to be the primary decision makers in managing their health condition, based on the idea that patients are more motivated to initiate and sustain behavioural changes of their own choice, rather than changes prescribed by others. This approach requires a collaborative relationship between the patient and the healthcare professional (HCP), rather than a more traditional paternalistic approach which gives the idea that the HCP knows best and that if only the patient does what the HCP tells them, all will be well.

Principles of empowerment have been described by Robert Anderson and Martha Funnell, from the USA, who have pioneered the concept. There is some emerging evidence of the value in this approach in developing self-efficacy and reducing the use of healthcare resources.

In the UK the "House of Care " approach to improving the care of people with long term conditions is being encouraged. This approach which includes a toolkit of resources to help HCP's and commissioners of care, has patient empowerment as central.

What does Patient empowerment mean?

It refers to a process where people gain greater control over decisions affecting their health. The principle is to enable patients to be the primary decision makers in managing their health condition, based on the idea that patients are more motivated to initiate and sustain behavioural changes of their own choice, rather than changes prescribed by others.[1] This approach requires a collaborative relationship between the patient and the healthcare professional. It has been pioneered in diabetes care over the past 20 or so years by Robert Anderson and Martha Funnell from the USA . They describe it as both a process and an outcome. [2] Empowerment is a process when the purpose of an educational intervention is to increase one's ability to think critically and act autonomously. Empowerment is an outcome when an enhanced sense of self-efficacy occurs as a result of the process. Empowerment is a continuous variable. [2] When using a scale such as the Diabetes Empowerment Scale (DES) [3] the strength and direction of change is an indication of the interventions effectiveness. Anderson and Funnel' list the foundational principles of empowerment [2] which are:

Fundamental Principles of Empowerment

  1. Patients provide 98% of their own diabetes care.
  2. The greatest impact on the patient's health and well-being is a result of their self-management decisions/actions during the routine conduct of their daily life.
  3. Diabetes is so woven into the fabric of the patient's life that many, if not most, of the routines of daily living affect and are affected by diabetes and its self-management.
  4. Because patients are in control of their daily self-management decisions, they are responsible for those decisions and the resulting consequences.
  5. Patients cannot surrender the control or responsibility they have for their diabetes self-management no matter how much they wish to do so. Even if patients turn their self-management completely over to a HCP, they can change their mind about that decision at any time. Thus, they remain in control at all times.
  6. Health care professionals cannot control and therefore cannot be responsible for the self-care decisions of their patients.
  7. HCPs are responsible for doing all they can to ensure their patients are making informed self-management decisions, i.e., informed by an adequate understanding of diabetes self-management and an awareness of the aspects of their personal lives that influence their self-management decisions.

Patient Empowerment as a Paradigm Shift for Healthcare Professionals

In many countries healthcare professionals (HCP's) are trained with a set of responsibilities and expectations that define their professional identity. These often become so embedded in their professional identity that they do not consciously think about them, rather they see their practice through them. One such paradigm is that for conditions such as diabetes HCP's have been trained in an approach to care based on a model of treating acute illness. However this model can cause more problems than it solves. In diabetes management there is an extensive literature on non compliance of patients with treatment [4] which is based on the view that the problem is the patients behaviour rather than the problem being the HCP's approach to care, which is seldom considered [2]. This paternalistic approach coveys the idea that the HCP knows best and that if only the patient does what the HCP tells them, all will be well.

It is possible to believe in the empowerment approach intellectually and yet behave in ways that contradict it without being aware of the contradiction. HCP's being trained in empowerment sometimes say that "I have just realised that I am trying to use the empowerment approach to try and get my patient to make the decision that I think best for them" [2] This contradiction can only be solved by HCP's changing their behaviour or their philosophy so that the two are consistent.

Is Patient Empowerment of Benefit?

In a systematic review of Web-based interventions to increase patient empowerment 14 randomised controlled trials were included, there were two in people with type 2 diabetes. [4] The authors concluded that in comparison with usual care or no care, Web based interventions had a significant positive effect on empowerment measured with the DES in 2 studies, and on self-efficacy measured with other disease specific self-efficacy scales in a further 9 studies.[5] In a cohort study of 1141 people with type 2 diabetes enrolled onto a Patient Empowerment Programme in Hong Kong . Participation in the course was associated with improving rates of HBA1c and LDL cholesterol achievement, with a reduced general outpatient clinic utilization rate. [1] In a systematic review and meta-analysis of group based diabetes self management education that included 21 studies two studies that reported an outcome of empowerment/self efficacy showed significant improvement [6]

How is patient empowerment being practised and encouraged?

In the UK there has been an approach to changing the focus of management of long term conditions in the NHS to enable the needs and views of the patient to become central to the care process. It was entitled "The Year of Care" [7] and the work has more recently been designated as the House of Care [8] It has been advocated and supported by NHS England who say that " The house of care takes a whole systems approach to long term condition management, which includes diabetes care. It makes the person central to care. It is about aligning levers, drivers, evidence and assets to enhance the quality of life for people with long term conditions" [8] A group of resources have been developed including an interactive Toolkit, an information dashboard and a diagnostic tool to help HCP's and organizations to make the changes necessary. The toolkit brings together national guidance, published evidence, local case studies and information for patients and their carers.[8]

One of the simple ways in which some of the concepts of empowerment can be incorporated into routine diabetes management is to ensure that every diabetes review appointment involves using open ended questions such as "what is the most difficult thing for you at present with your diabetes?", "what goal(s) do you want to set for improving your diabetes in the few months?", and "what new information do you need to help you with managing your diabetes"

References

  1. ^ Wong CK, Wong WC, Lam CL et al Effects of Patient Empowerment Programme (PEP) on Clinical Outcomes and Health Service Utilization in Type 2 Diabetes in Primary Care: An observational matched cohort study. PLOS One 9(5) 2014:e95328 doi:e95328.doi:10.1371/journal.pone.0095328

  2. ^ Anderson RM, Funnell MM Patient Empowerment: Myths and Misconceptions Patient Educ Couns 2010 79:277-282. Doi:10.1016/j.pec.2009.07.025

  3. ^ Anderson RM, Funnell MM, Fitzgerald JT, Marrero DG The Diabetes Empowerment Scale: a measure of psycho-social self-efficacy. Diabetes Care 2000; 23:739-743

  4. ^ Bailey CJ, Kodack M Patient Adherence to medication requirements for therapy of type 2 diabetes : Review Article Int.' Clin Pract 2011 65: 314-322

  5. ^ Samoocha D, Bruinvels DJ, Elbers NA et al Effectiveness of Web-Based Interventions on Patient

  6. ^ Steinbekk A, Rygg LO, Lisulo M, Rise MB, Fretheim A Group based diabetes self management

  7. ^ http://www.yearofcare.co.uk/ last accessed 10 Nov 2014

  8. ^ http://www.england.nhs.uk/house of care last accessed 10 Nov 2014

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