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Jordan University of Science and Technology Faculty of Nursing
Concept analysis paper: Empowerment
Prepared by: Ashraf Ali AlSmadi
Advised by: Dr.Nemeh AlKour RN, PhD
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Introduction: The concept has been used to give different meanings. (Melies, 1991) said that a concept is vital to build the scientific theory, research and theory development, and it is the description of a phenomenon. On the other hand, King (1988) explained it as an idea or mental image of reality. Empowerment concept is explained and defined by various disciplines; including: social work, psychology, education, community psychology, and nursing. In addition, Empowerment concept is lately used in different phenomenon, such as: student empowerment, empowerment of teachers, empowerment of patient and empowerment of nurses. From reviewing the related literature of the concept in the nursing field, there is no specific definition of empowerment because it is used depending on the writer and the framework of his/ her paper. According to (Norries, 1982) one of the major problems with the nursing science is that its concepts are words that lack the elements of the system that are necessary for a scientific discipline (e.g. categories, taxonomies and rules). For that, the writer will present a concept analysis of empowerment which will identify and examine its attributes, characteristics, antecedents, consequences and uses of the concept in the nursing field. According to the assumptions for this concept analysis paper, the writer believes that each nurse manager must empower his/her followers' autonomy, accountability, decision making abilities, problem solving, and managerial skills. Usually an analysis of the concept is held to clarify its meaning and to show the relations of its elements in various fields. In this paper the concept of empowerment will be studied in the field of nursing to clarify its meaning to develop nursing knowledge base and to show its importance in this profession. As the writer believes that when the nurses are empowered, the productivity and effectiveness of the nursing health care services will
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increase. The empowerment is a complex concept, for example, it is easy to be understood, however; it is hard to be defined. Literature Review: From the literature of empowerment, it is difficult to be found as an independent concept since it's linked with other concepts, such as: coping skills, personal efficacy, support system, community organization, mutual support, neighborhood participation, competence, self esteem, and self sufficiency (Kieffer, 1984). Empowerment concept emphasized by World Health Organization through the definition of health promotion as a "process of enabling people to increase control over and to improve their own health" (Maglacas, 1988). Furthermore, the concept of empowerment is not only captured by personal responsibility in performing health, it more requires the effect of the social environment on personal health (Maglacas, 1988). The American Association of Colleges of Nursing (AACN, 1986) suggestions for an educated nurse that fits the definition of an empowered nurse " the graduate well exhibit qualities of mine and character that are necessary to live a free and fulfilling live, act in the public interest locally and globally, and contribute to health care improvements and the nursing profession". During the process of empowerment the individuals must have a strong commitment to achieve the goals of empowerment in effective ways (Rogers, 1983; Green, 1986; Report, 1989; Ellsworth, 1989). The concept empowerment derived from the Latin word 'potere'meaning "to be able" (McLeod, 1987). Empowerment has been examined by different sciences and multiple definitions were put forward. Linguistically, empowerment was defined in Webster's New World Dictionary of the American Language (Guralnik, 1970) as follows: the verb Empower is "To give power or authority to, authorize; to give the ability to, enable, and permit"'. The suffix 'ment' is defined as a "result or product". As a result, empowerment is the result of empowering. "A synonym for empower include to give or confer power, invest, endue,
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endow, strengthen, arm and delegate" (Chapman, 1977). More over, The Shorter Oxford English Dictionary (1989) defined the verb to empower as "to invest legally with power, to authorize, to license; to impart power; to enable, to permit". Merriam Webster's Third New International Dictionary (1993) defined empowerment as: "to give official authority to, delegate legal power to, and to give faculties or abilities to". Sociologically, empowerment is the action of increase the influence of a social group (kuokkanen, Leinokilpi and Katajisto, 2003). Rappaport (1981) defined empowerment as: a worldview that have a method to the solution of social problems and social policy a stemming from powerlessness". Berger and Neuhaus (1977) defined empowerment as: an approach of supporting the good services by social organizations. Solomon (1976, 1985) proposed empowerment as: an approach of social activities. Individual empowerment helps in making healthpromotional changes as it enhances the motivations by using some counseling techniques (McWhirter, 1991; Fahlberg LL, 1991 & Parsons RJ, 1991). Clifford (1992) and Johnson (1992) defined empowerment as: a dyadic process including thoughts or thinking and behaving. Gibson (1991) defined empowerment as: the individual's recognition, promotion and improvement of his abilities to achieve his own requirements, solve their own problems and mobilize resources to control their own lives by helping them to build a critical awareness of the situation and ease the proposition of a plan of action. Zimmerman and Rappaport (1988) defined empowerment as: a build that connects personal capabilities and power, positive behaviors and natural healing systems to issues of social change and social policy. In social psychology, empowerment is the personal growth and developments were the qualities, efforts and values are inherent in the person himself. (Kuokkanen, Kilpi & Katajisto, 2003). Browne (1995) stated that empowerment is the method that is used to change the workers' ability to function. Furthermore, Simmons and Persons (1983) added that
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empowerment is a method that makes the individual able to control his environment and achieve selfdetermination. This may happen by adopting an individual change, interpersonal change, interactional change or changing the social structure to that have an impact on the person. Zimman (1990) explained empowerment as a multi level build that happen at three levels: individual, organizational, and community level. In addition, nursing literature held many definitions of empowerment. In nursing and for the purpose of this paper, empowerment is the process of enabling the nurses to work efficiently through some activities that are named empowering. Those activities were classified into analytic nursing, change activities, funding and collegiality (Gorman & Clark's, 1986). Client empowerment was defined as a process initiating from nurses staff, "enabling individuals to feel effective so that they can successfully execute their jobs". Chandler (1992) proposed two definitions of "enabling" existed in relation to the empowerment in nursing; either positive or negative denotation. The positive denotation of enabling explains a professional in the mental health who helps patients in their acceptance back into society. The negative denotation of the enabling is to let an individual maintenance of substance abuse or other negative health habits (Campbell, 1996). In summary, from my perspective as a nursing management student, empowerment in nursing management is a process performed through delegating power or authority to staff nurses to assist them to control or lead, to increase ability to problem solving, and to increase quality of nursing care services. For this paper, empowerment is defined as an interactive process through a nursepatient or nursemultidisciplinary team relationship considered to help or assist in changing behaviors.
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Defining Characteristics of the empowerment concept: The empowerment concept is a communicational concept because the process of empowerment includes a connection with individuals. Although empowerment entail an individual needs, it is nurtured by the outcome of mutual efforts (Kieffer, 1984). Wallerstein and Bernstein (1988) said that the empowerment includes more than growing one's self confidence and efficiency or supporting optimistic health behaviors in persons; it includes environmental modification too. The reason of difficulty to find a specific definition of empowerment is that empowerment concept is changeable. It varies depending on the researcher and the situation. Therefore, empowerment meaning depends on the context. Wallerstein; Bernstein, (1988), and Kiffer, (1984), empowerment is not able to be defined in a single method: it requires to be cleared by the individual concerns (Rappaport, 1984). Katz, (1984) explained empowerment in that it has intrinsic and extrinsic connection between persons and society empowerment. He presented empowerment within a wholeness paradigm where persons are interdependent, there is a mutual exchange of resources, and partnership is enhanced. Obviously, a systems approach is essential to learn empowerment (Hess, 1984) as the concept has different views and also it's concern on solutions more than problems (Kiffer, 1984). It titled person's strengths, abilities, and human rights more than requirements and shortage. Consequently, the process of empowerment encompasses prospective activities that done prior to work. Empowerment is a positive, changeable or dynamic concept (Hess 1984). Empowerment concept reveal a female perspective of power, in which power is conceptualized as a circumstance of being able to perform some purpose in collaboration with individuals, on the contrary with a male perspective of power somewhere there is an inadequate provide that must be effort for and protected against others (Hurty, 1984, Watt's, 1990, Wheeler and Chin, 1989). Also we can say the empowerment is a democratic concept
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because the process of empowerment proposes a rearrangement of power and improvement of social justice. (Hegar & Hunzeker, 1988). Empowerment can be regarded as an argumentative concept, because during the process of empowerment, it is able to change locations in the process and results. (Kataz, 1984 & Rappaport, 1984). In addition, empowerment is an improvement concept where persons, groups, families and communities increase and potential are improved. Rappaport, (1984). In the process of empowerment, inconsistency, tension, and expansion are complex intertwined, therefore; complex solutions of problems are important in a way that they make old problems never appear again.
Attributes of Empowerment: The attributes of empowerment concept that were defined in the literature are (Rodwell, 1996 and Hawks, 1992): 1. Collaborative process between two or more individuals characterized by open communication, and common goal setting. 2. The availability of alternatives of decisions and the acceptance of accountability. 3. Reciprocal decision making in mobilizing the resources, the opportunities that are available, and rightly using the power. 4. Helping process. 5. Interdependent participation between the patients and the nurses, dynamic listening that will help each party to have experience and learn from others, and personal knowledge or cognitive acquisitions gained from each other (Zimmerman et al, 1991). 6. Adds educating, leading, mentoring, providing, structuring, and actualizing (Vogt & Murrell, 1990).
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7. Offers uptodate improvement, promotion, support and focus on the development of individual's relationships (Craddock and Skinner, 2000). 8. Finally, in an attempt to empower individuals, the person requires some attributes such as loyalty, instinctive thoughts, elasticity or flexibility, respect of diversity, supportive, courage, readiness to negotiation and understanding (Katz, 1984; Pinderhughes, 1983 & Watts, 1990).
Related concepts: Related concepts are concepts which give the same meaning of empowerment concept, (Rodgers, 1989). The related concepts of empowerment are: 1. Accountability. 2. Liability. 3. Alternative. 4. Power. 5. Encouragement. 6. Enthusiasm. 7. Authority. 8. Responsibility.
Antecedent situations are essential circumstances that must occur prior to the empowerment process begins. Respect is a vital antecedent to the empowerment process because a person must always have respect and attentiveness for individuals' believes and values (Tones, 1986, Manthey, 1992). In addition, education is a very significant transporter for empowerment persons (Mason, et al, 1991; D'onofrio, 1992). In the same way; trust is a
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cornerstone to empowerment that develops from directness, integrity, authenticity, open communication, and mutual relation between the individuals. The empowerer must trust personal abilities to accept accountability, responsibility, and make decision. (Hawks, 1992; Manthey, 1992). The shared commitment is very important antecedent, because the empowerment will not be successful if both individuals are not committed to the process. Also inspiration and contribution are very significant antecedents to perform the process of empowerment in a success way (Labonte, 1989 & O'neill, 1992). Persons also must have the ability to think about how human behaviors need to be changed, by thinking about the advantage and disadvantage of behavior change, and problem solving with persons to achieve the goal of behavior change (McWhirter, 1991; Connelly & Keele, 1993; Worrell & McGinn , 1987). The empowerer must acquire and use specialized skills, knowledge, good manners, and recognition of some behaviors that promote empowerment, For example, an antecedent of empowerment in the health care sector related to patient empowerment is a nursing staff empowerment. As an empowered nursing staffs, the RN's will recognize from their previous knowledge and experiences about the communication and distribution of power. Consequently, the empowered RN's will have a structure of references and will recognize the impact of their personal power base. For these nurses, the nursepatient relationship will be improved by patient empowerment. Conversely, for the nurses who are not knowledgeable about the empowerment, the roles of nurses and empowered patients will give unclear impression with no clear line of responsibility. Then, most likely, the nurses will feel in jeopardy, and at risk with patient empowerment. (Gurley, 1995).
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Consequences refer to product, result or outcomes of the empowerment process. The outcome of empowerment process encloses improved selfconfidence (Tones, 1986; Mason, et al, 1991). A sense of manage over life and the alteration of processes (French, 1990, Mason et al. 1991, Zerwek, 1992). The capability to put and achieve goals (French, 1990).The empowerment process is a verification of thoughts, ambitions, abilities, and one's principles, believes, and values (Mason, et al, 1991). Accordingly, the empowerment process includes alteration of awareness, in which the borders of personality develop into more transparent and expand with the intention that a sense of attachment will produce (Wallerstein and Bernstein, 1988). The result of the ability to empower persons, families, and communities, as revealed in the literature, involved: self improvement, a feeling of trust, selfefficiency, a sense of attachment, personal satisfaction, a sense to manage or control, enhance ability to problem solving, communication, leadership and management skills, get better quality of life, and social fairness (American nurse's foundation, 1989, Dunst et, al.1988, Kieffer, 1984, labonte, 1989, Wallenstein and Bernstien, 1988). The consequences of patient empowerment process in the health care sector arrive further than patient outcomes. Furthermore, the consequences of patient empowerment consist of doctor impact, healthcare payer impact, nursing staff impact, regulation and policy impact, and organizational impact. (Craddock and Skinner, 2000). Empowerment moves toward diminishing the sense of gratitude felt by the patient to the nurse. As a result, the psychological costs of accepting help are diminished. (Dunst et, al. 1988).
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Application to nursing
Ammar, a 62yearold post mitral valve replacement surgery patient, arrived at the hospitalbased cardiac rehabilitation clinic in King Abdullah University Hospital with his son. The cardiac rehabilitation nurse Ashraf took them into special room, where he spent about one assessing physical, psychosocial, and cultural aspects (showing signs of strong participation, acquiring knowledge, and good individual listening). Ashraf, after finishing physical assessment, gave some instructions about benefits of home exercise, how to monitor blood pressure and weight, and explained a plan for dietary changes related to sodium and fat restrictions (Active listening by the patient and his son). Ashraf described the benefits of this rehabilitation program, and took feedback from the patient and his son to evaluate their knowledge about the instructions given (strong listening by Ashraf). Also, he gave written instructions. The patient expressed some fears and stress during rehabilitation exercises. At the second day, the patient asked Ashraf about the range of exercises that must be completed. (Exhibiting personalized information and good listening to help patient and his son about health behavior changes).Ammar followed the instructions given to him by Ashraf and kept in contact with Ashraf for any explanations needed later. The program was successfully achieved, as proofed by decreased serum lipids and increased exercise tolerance. Ammar demonstrated compliance in attending appointments at the cardiac clinic, and kept the latest modifications of his life style on. The given example illustrated good listening; acquired knowledge, and active participation by Ashraf and Ammar in the process of empowerment. Ashraf participated by assuming the role of facilitator and giver of knowledge for these specific groups of patients, and afforded mutual listening to patient comments, and personalized information for Ammar
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and his son to get the maximum benefit. Ammar adapted health behavior changes through following rehabilitation program instruction Contrary case Ahmad a 51yearold teacher who diagnosed as unstable angina by the residence doctor at the Emergency room of King Abdullah university hospital. Ahmad has feel of tiredness and fatigue while he was teaching a class in the school. Some of the students advise the teacher to rest his self and after she noted that the teacher was sweaty, unsteady and the discoloration of his skin has been started. Suddenly the teacher was laying in the floor, emergency medical services brought teacher Ahmad to emergency room of King Abdullah hospital, after the doctor has diagnosed Ahmad unstable angina, Ashram who was a good nurse has assigned to work with Ahmad case, started to teach Ahmad how to deal with his disease by the appropriate medical method to prevent further complication or any advancement related to his disease process. Ahmad was ignoring Ashraf dialogue and was asking Ashraf to complete his communication, because he was want to smoke a cigarette (lack of participation, a defining attribute). After with, Ahmed has returned to the hospital emergency room by emergency medical services with three of students, they were worry about their teacher, the cardio pulmonary resuscitation established at emergency room because of cardiac stopping. Students inform the nurse that teacher was smoking post each class, and so on till they brought him to the emergency room. Autopsy shows progressive of disease process proofed by myocardial infarction. Ahmad case shows lack of active participation and good listening with nurse, so no empowerment process achieved, Ahmad non compliance to the healthy behavior that was in order to changing his habit exemplified the opposite of empowerment .
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