Empowerment Approach to Diabetes Education: Promises and Challenges

1. Empowerment Approach to Diabetes Education: Promises and Challenges 25 March 2006 (12-13:00) Society of Nursing Education Kan, Eva Shiu, Ann TY and Wong, Rebecca

2. Empowerment: Meaning • A common terminology • New public health and health promotion: Specific meaning • The WHO definition (1998) • Empowerment is a process through which people gain greater control over decisions and actions affecting their health.

3. Relevance to nursing practice Tones (1998) • Self-empowerment model of health education (patient education) is suitable for nursing practice in the context of individual or small group education encounters. • This is the area where nursing practice can operationalise the concept of ‘health promotion at the micro level’.

4. The literature shows a paradigm shift • Diabetes • A chronic illness • Over 95% of decision-making • Self-managed illness • Active engagement of patients • Education as the corner-stone

5. Diabetes research priority • A cursory MEDLINE search: over 450 citations of compliance in the title (all inclusive = 8000) • 21st century as an era of researching effective models of diabetes care delivery • In particular what model of care can better elicit patients’ cooperation

6. Diabetes education research • A gradual shift since 1990s: from a traditional/didactic/preventive model to an empowerment approach • The limitation of the preventive approach: knowledge does not always lead to change in behaviour, e.g., a systematic review 2004 • As exemplar pioneering the shift in the patient education arena

7. A general agreement at the end of 1990s • Patients as active and informed participants • A preventive (compliance/adherence) model is an acute illness model • Empowering patients to take control of both physiological and psychological outcomes – to be the major underpinning philosophy of care provision

8. In the new public health era, a preventive model to patient educationis regarded as • Without paying attention to psychosocial and economic factors • Imposing values • Victim blaming

9. Victim blaming Consists of • “Ignoring the broader social, material, economic and cultural factors determining individual behaviour and • placing the entire burden of responsibility for action on individuals (victims) themselves while, • at the same time, not recognising the limits to the individual’s power to act and, • on occasions, denying the individual the opportunity to take responsibility when he or she actually has some scope for making choices”(Tones and Tilford, 2001).

10. Prevention of diabetes complications • Extremely important: A goal of diabetes education • But may become victim blaming • when the environmental factors are ignored or • when patients’ opportunity to take responsibility and make choices are denied

11. Facilitating active engagement of patients • The approach to diabetes care should change from compliance to empowerment • does not abandon educating for knowledge • but goes beyond it • The shift is likely to • enhance knowledge and cooperation • foster appropriate self-management abilities • enable patients to overcome some of the personal, social and environmental barriers

12. An empowerment paradigm • Education strategies derived from the empowerment model may be more effective in achieving prevention of diabetes complications • For example, A randomised control trial study shows that patient empowerment can improve patient outcomes such as HbA1c and QoL (Anderson et al., 1995)

13. Empowerment as the philosophy • The Anderson team at Michigan started advocating patient empowerment in the 1990s • ‘This philosophy is based on the assumption that to be healthy, people need to have the psychosocial skills to bring about changes in • their personal behaviour, • their social situations, and • the institutions that influence their lives. These skills probably play an important role in the development and implementation of a successful diabetes self-care plan, i.e., a plan that enhances the patient’s health and quality of life’(Anderson et al., 1995).

14. Empowerment as the education process • Aims at facilitating patients’ sense of control (confidence) in • Achieving goals • Overcoming barriers • Determining suitable methods • Obtaining support • Coping

15. Empowerment as the outcome • Include self-efficacy beliefs, sense of coherence, self esteem • To assess the outcome of programmes guided by patient empowerment, a measure of meaning to the philosophy should be used • Anderson et al. (1995) developed and psychometrically tested the Diabetes Empowerment Scale – measures diabetes psychosocial self-efficacy

16. How to implement empowerment in education encounters • Clarify and internalise the philosophy • Beliefs about diabetes self-management • Values and associated beliefs about diabetes education • A deep reflection on the roles and responsibilities • Develop awareness of the basic assumptions of the use of this and other theoretical models • Use education strategies of meaning to the self-empowerment model • Two-way communication • Mutual respect: two experts • Experiential learning activities

17. Scenarios and Discussions • Some scenarios from our clinical experience Aim to stimulate discussion on • (1) promises and • (2) challenges of implementing empowerment in diabetes education, which may include the constraints arising from • the patient, • the nurse, and • the context