Patient Education and Counseling 103 (2020) 1263–1271

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Patient Education and Counseling

journal homepage: www.elsevier.com/locate/pateducou

Review Article

Empowerment in healthcare: A thematic synthesis and critical

discussion of concept analyses of empowerment
Kristin Halvorsen* ,1, Alfhild Dihle1, Camilla Hansen, Marita Nordhaug, Heidi Jerpseth,
Sidsel Tveiten, Pål Joranger, Ingrid Ruud Knutsen
Faculty of Health Sciences, Institute of Nursing and health Promotion, Oslo Metropolitan University, Postbox 4, St. Olavs Plass, N-0130 Oslo, Norway

A R T I C L E I N F O A B S T R A C T

Article history: Objective: The objective of this study is to shed light on common characteristics revealed in concept
Received 5 November 2019 analyses of empowerment to contribute to further understanding. A further objective is to discuss how
Received in revised form 5 February 2020 the perspective of healthcare service users appeared in the concept analyses.
Accepted 12 February 2020
Methods: The review was performed by systematically searching Medline, CINAHL, EMBASE, PsycINFO
and ERIC. The search yielded 255 abstracts, which were reduced by relevance and critical appraisal to the
Keywords: 12 concept analyses included. The analysis process involved thematic synthesis as described by Thomas
Empowerment
and Harden.
Concept analysis
Patient participation
Results: The synthesis led to 13 descriptive themes structured according to antecedents, attributes and
User experiences consequences of empowerment. The synthesis revealed how sparsely the question of equality and power
User involvement in the relation between health professionals and healthcare service users is addressed.
Thematic synthesis Discussion: To a great extent empowerment is viewed as a helping process of making patients act
differently, rather than redistribution of power. For groups that are particularly vulnerable to oppression,
questions of power are of severe importance.
Practice implications: As user participation is a growing discourse in health policy, health professionals
need education to develop and address dimensions of power and reciprocity in empowering relations
between users and themselves.
© 2020 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1264
1.1. Objective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1264
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1264
2.1. Eligibility criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1264
2.2. Databases and search strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1264
2.3. Selection of articles and critical appraisal . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1265
2.4. Data extraction and analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1265
2.4.1. Coding the text . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1265
2.4.2. Developing descriptive and analytical themes . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1265
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1266
3.1. The included articles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1266
3.2. The common characteristics – descriptive themes . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1266
3.2.1. Descriptive themes reflecting antecedents to empowerment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1266
3.2.2. Descriptive themes reflecting attributes of empowerment . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1268

* Corresponding author.
E-mail addresses: kristin.halvorsen@oslomet.no (K. Halvorsen), alfhild.dihle@oslomet.no (A. Dihle), camilla.hansen@oslomet.no (C. Hansen),
marita.nordhaug@oslomet.no (M. Nordhaug), heidi.jerpseth@oslomet.no (H. Jerpseth), sidsel.tveiten@oslomet.no (S. Tveiten), pal.joranger@oslomet.no (P. Joranger),
ingrid.ruud.knutsen@oslomet.no (I. Ruud Knutsen).
1
Shared first authorship.

https://doi.org/10.1016/j.pec.2020.02.017
0738-3991/© 2020 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
1264 K. Halvorsen et al. / Patient Education and Counseling 103 (2020) 1263–1271

3.2.3. Descriptive themes reflecting consequences of empowerment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1268

3.3. Analytical themes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1269
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1269
4.1. Study limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1270
5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1270
5.1. Practice implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1270
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1270
Authors’ contributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1270
Acknowledgement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1270
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1270

1. Introduction 1.1. Objective

Empowerment as a scientific concept emerged in the literature
in the 1960s and 70s, particularly in relation to civil rights and
democratization processes in e.g. South Africa, South America and
the US. Empowerment is rooted in social action and aims to
increase the autonomy, power and influence of oppressed groups.
Lack of empowerment was associated with the patriarchal and
authoritarian concept of power [1,2,3]. In this context, power refers
to status and to the possibility to control people, their actions and
economic resources. The political ideals of empowerment were to
draw attention to the capacities and abilities of individuals, to
promote power and participation, rather than focusing on their
deficits and needs [1–3].
In 1986, the World Health Organization (WHO) introduced the
new public health strategy in the Ottawa Charter [4]. Three main
principles can be interpreted from this 1) Redistribution of power
from health professionals to healthcare service users, 2) Participation
and 3) The healthcare service user as an expert on him/herself. The
increased focus on empowerment is described as representing a
shift from a paternalistic to a participatory way of thinking about
health and healthcare [2–5]. Consequences following this are that
user participation, involvement and health competency are given
increased attention in healthcare and research the last two
decades.
According to several authors, empowerment is seen as a
concept, a process and as a result [6–8]. Moreover, empowerment
is a widely used concept, described to take place on different levels,
from a political macro level to the level of groups and individuals
[2]. Knol and van Linge [9] lean on the work of Quinn and Spreitzer
[10] to describe individual empowerment as a cognitive motiva-
tional factor coming from within. Theories of empowerment refer
to a dynamic understanding, directed at solutions, growth and
development in achieving empowerment on individual and
societal levels. These theoretical perspectives have a common
focus on the power in empowerment, which is addressed in
different studies, e.g. by Spence and Tengland [11,6]. VanderPlaat
underlines that empowerment is not something “given”; more-
over, power is something “equally taken” in equal relations [12].
Over the years, different theoretical perspectives have been
used to understand how empowerment unfolds, drawing on e.g.
psychology, sociology, management and critical social science
[7,12]. In healthcare theory, empowerment is termed an ideology
[13], a paradigm [14] and a philosophy [11], illuminating the broad
understanding of empowerment.
Several concept analyses have been performed in the last 20
years in order to explain and define empowerment as a concept. To
our knowledge, there are no papers synthesizing concept analyses
of empowerment. A synthesis may contribute to further under-
standing of the concept and initiate new discussions of how to
understand the concept for the future. As empowerment involves a
participatory way of thinking, it seems reasonable to explore how
perspectives of healthcare service users appear when empower-
ment is approached as a concept.
The objective of this paper is to assemble concept analyses on
empowerment to achieve a deeper understanding of the perspec-
tive of the healthcare service user.
The following research question were asked:
i What are the common characteristics of empowerment in
concept analyses of empowerment from the perspective of the
healthcare service user?
ii How is the healthcare service user perspective revealed in
concept analyses of empowerment?
2. Methods
The method chosen for synthesizing concept analyses of
empowerment is thematic synthesis as described by Thomas and
Harden [15]. Their development of thematic synthesis is built on
the approach to meta-ethnography developed by Noblit and Hare,
and is rooted in the research tradition of grounded theory [15]. The
method consists of three stages: 1) coding text 2) developing
descriptive themes and 3) generating analytical themes. As in all
types of systematic reviews, the process of searching for and
selecting relevant research is highlighted as an important aspect of
a thematic synthesis of high quality, and this is also described by
Thomas and Harden [15]. Performing this protocol driven synthesis
the PRISMA checklist is followed (Appendix 1, Supplementary
material).
2.1. Eligibility criteria
To ensure a broad perspective of the concept of empowerment,
our inclusion criteria were initially comprehensive and included
various concepts related to empowerment. The inclusion criteria
were (i) concept analyses of Empowerment, Partnership in
healthcare, Health promotion, Health literacy, Health assessment,
Health Coaching, Health efficacy, Co-production, Citizenship,
Healthcare supervision, Health supervision, (ii) concept analyses
based on both primary and review studies, (iii) studies focusing on
the user perspective in healthcare, (iv) studies published in
English, Danish, Norwegian or Swedish, (v) studies involving adults
(18+), (vi) studies published since the Ottawa Charter in 1986.
Exclusion criteria were (i) studies involving people under 18, (ii)
qualitative or quantitative individual studies without a concept
analysis, (iii) a concept analysis that drew only on theoretical
perspectives, (iv) a concept analysis from a nursing or healthcare
provider perspective or from an organizational and management
perspective, (v) studies published before 1986.
2.2. Databases and search strategy
A systematic search was conducted in the databases Medline,
CINAHL, EMBASE, PsycINFO and ERIC. Additionally, we searched for
 K. Halvorsen et al. / Patient Education and Counseling 103 (2020) 1263–1271
relevant concept analyses from the reference lists of all articles
read in full text. Search terms were combined by using the Boolean
terms “or” and “and”. For all of the databases, the search terms
were used as both keywords and MeSH terms according to the
different databases. We searched for publications from 1 January
1986 to 31 August 2019. A complete search history from CINAHL is
found in Fig. 1.
2.3. Selection of articles and critical appraisal
Four of the authors conducted the main searches. Our searches
resulted in 255 relevant hits after all duplicates were removed. The
abstracts of these were screened and 83 relevant articles were
included where the terms empowerment and concept analysis
were found in the title or abstract, or in both. All 83 articles were
read in full text by pairs of authors, and discussed by all authors.
After the reference lists were screened, one more article was
added. After the full-text reading, 70 articles were excluded
because they were not concept analyses of empowerment, not
based on empirical studies or for quality reasons. All articles that
did not include concept analysis of empowerment in title or
abstract were excluded. Thirteen articles were then re-read in full
text by all authors.
A critical appraisal was performed using the Joanna Briggs
Institute Critical Appraisal Tool (http://joannabriggs.org/research/
critical-appraisal-tools.html) [16]. The appraisal tool for system-
atic reviews was chosen as the most appropriate, since most of the
included concept analyses were based on reviews of research. One
article was excluded due to methodological weakness. Twelve
concept analyses were included (Fig. 2).
All the included articles, their methods of concept analysis,
their empirical basis and the results of the critical appraisal are
shown in Table 1.
2.4. Data extraction and analysis
Most of the included concept analyses approached the concept
of empowerment in three dimensions: 1) antecedents, 2) attributes
and 3) consequences. For that reason, antecedents, attributes and
Fig. 1. Complete Search history in CINAHL.
1265
consequences were useful tools in the analytical process and
constituted a framework in the data extraction and analysis in this
paper. Antecedents are those events or incidents that must take
place prior to the occurrence of the concept in focus. Attributes are
described as what characterize and give the best insight into
empowerment, while consequences are the conditions or changes
that arise as a result of empowerment.
2.4.1. Coding the text
The coding process was performed line by line, article by article,
as a back and forth process according to meaning and content, as
recommended by Thomas and Harden [15]. The coding process
consisted of finding both main and sub-codes. The codes were
given separate colours to aid visibility. During the coding process,
the codes were split and merged. The way the codes emerged
across the articles was described. Table 2 shows an overview of the
identified codes across the selected articles.
2.4.2. Developing descriptive and analytical themes
During the coding process, descriptive main and sub-themes
reflecting the concept of empowerment across the articles
became more evident. The descriptive themes represent the
common characteristics of empowerment, according to research
question i, framed within antecedents, attributes and conse-
quences of the concept of empowerment. Thirteen descriptive
themes were developed (Table 3). The descriptive themes
reflected research question i, focusing on the common character-
istics of the concept of empowerment found across the concept
analyses, structured according to antecedents, attributes and
consequences. According to Thomas and Harden [15], the
objective of creating analytical themes is to translate and
synthesize the findings from the descriptive themes into a higher
understanding, adding something more to the understanding of
the concept, here empowerment. Based on the descriptive
themes and research question ii, two analytical themes were
established to gain a more comprehensive understanding for a
discussion of how the healthcare service user perspective became
apparent in the concept of empowerment.
1266 K. Halvorsen et al. / Patient Education and Counseling 103 (2020) 1263–1271
Fig. 2. Flow diagram of included and excluded articles in the synthesis.
3. Results
3.1. The included articles
The data consisted of twelve concept analyses of empower-
ment, but these described the concept in relation to different
contexts, user groups, countries and methods of concept analysis.
The contexts reflected in our included articles were both hospitals
and homecare/community healthcare. The user groups included
patients with epilepsy, chronic obstructive pulmonary disease
(COPD), chronic illness in general and mental health challenges,
and patients in intensive care, hospital patients in general,
patients in general and user groups in midwifery and in health
promotion. Two of the selected articles were based on primary
empirical studies of user experiences [17,18], while the other ten
had reviews based on user experiences as the basis for their
concept analysis. Some of these reviews focused on both users
and health professionals. However, our focus was only on
healthcare service users. An overview of the included studies is
presented in Table 1.
3.2. The common characteristics – descriptive themes
In developing the descriptive themes, it was important to be as
descriptive as possible to ensure that all the common character-
istics of the concept of empowerment in the selected articles were
reflected in the themes. In the included articles, we found
overlapping themes of the antecedents, attributes and conse-
quences. In the analysis, overlapping values and properties could
occur in different phases of the empowerment process. The themes
are presented in Table 3.
3.2.1. Descriptive themes reflecting antecedents to empowerment
Antecedents are those events or incidents that must take place
prior to the occurrence of the concept in focus. In this review, it
implies what are the prerequisites for the empowerment process
being an issue. What initiate the need for empowerment? The
range of the antecedents are wide and represent extremes of
experiences from powerlessness to partnership in relations. The
antecedents are thematised according to commonality and width
of characteristics.
3.2.1.1. Powerlessness, loss of control, stigma and/or need of
competence. Five papers describe experiences of
powerlessness, loss of control and stigma as common
antecedents of empowerment [18–21]. Bennett et al. [22] argue
that loss of power and control is required for empowerment to
occur, and describes how e.g. people with epilepsy feel less
empowered when dealing with services, relating this to a lack of
information and poor quality of consultations. They also argue
that stigma based on the epilepsy diagnosis underlines the feeling
of being disempowered. Another related prerequisite for
empowerment is being in need of competence, referring to
patients’ need of competence and development of the necessary
knowledge, skills and attitudes to make choices on issues
important to them [22–25].
3.2.1.2. Motivation, change and/or transition. Motivation is
described as important [19,21,22,24,26,27]. Wahlin [27] explains
 K. Halvorsen et al. / Patient Education and Counseling 103 (2020) 1263–1271 1267

Table 1
Matrix of included studies.

Authors/Year/ Aim Method of concept analysis Setting/Participants Critical

Country appraisal
1 Bennett et al., To undertake a concept analysis of empowerment with Synthesis of Norris’ and Rodgers’ Epilepsy services Patients with Good
2016 Ireland reference to epilepsy services methods Review of 159 articles epilepsy and their providers
2 Castro et al., To clarify the meaning of the overlapping concepts of patient Walker & Avant and Haase et al. Hospital care Patient group not Good
2016 Belgium empowerment, patient participation and patient-centredness Review of 103 articles specified
3 Dowling et al., To explicate a model of empowerment appropriate to clients Synthesis of Norris’ and Rodgers’ Setting not specified Patients with Average
2011 Ireland living with a chronic illness, in particular COPD methods Review, number of chronic illness, in particular COPD
articles not specified
4 Finfgeld, 2004 To examine concept analyses related to empowerment, Walker & Avant Review, number of Setting not specified Individuals Average
USA evaluate ways in which quality findings support these articles not specified with mental health problems
analyses, and propose a model based on this work
5 Fotoukian To clarify the meaning and the nature of the empowerment A hybrid model, Rodgers and Hospital care 7 old people with Good
et al., 2014 Iran concept in relation to some older Iranians suffering from Knafl. Literature review/ chronic diseases, 1 head nurse, 1
chronic diseases integrative review with 60 articles nurse, 1 nursing instructor, 3
included family members
6 Gibson, 1991 To define the concept of empowerment and determine if this A synthesis of strategies from Setting not specified Individuals, Poor
USA concept has some utility for nursing practice Norris, Rodgers, Schwartz-Barcott families and communities
& Kim and Walker & Avant
Literature review
7 Hermansson & To analyse the empowerment concept in the midwifery Hybrid model Schwartz-Barcott & Prenatal clinics, delivery and Good
Mårtensson, context, focusing on the childbearing period, with the aim of Kim Literature review maternity wards 9 midwives and
2010 Sweden clarifying its meaning in order to enable comprehension and 12 couples
use in clinical practice, education and research
8 Holmström & To explore and compare the concepts of patient-centredness Walker & Avant Review of Health professionals Patients, Average
Röing, 2010 and patient empowerment, and clarify a possible relationship theoretical and empirical numbers and types not specified
Sweden between the two from the perspective of the encounter literature with 40 articles
between patients and their healthcare providers included
9 McCarthy, To examine the attributes, characteristics, and uses of Walker & Avant Literature review Not specified Average
2008 empowerment within diverse disciplines to clarify its
meaning and explore its potential application to nursing
challenges that cross settings, disciplines, and time
10 Ntshingila To define the central concept of “facilitation of self- Walker & Avant Initial steps of Women with borderline Average
et al., 2016 empowerment” of women living with borderline personality Chinn & Kramer Review of personality Numbers unknown
South Africa disorder literature
11 Rodwell, 1996 An analysis of the concept of empowerment and its use in Walker & Avant Rodgers Literature Not specified Poor
England nursing practice, education, research and health promotion review
12 Wåhlin, 2017 To analyse how the concept of empowerment is defined in the Walker & Avant Literature review ICU patients were in focus in six of Good
Sweden scientific literature in relation to critical care. As 22 articles were found to these articles, next of kin in four
empowerment is a mutual process affecting all individuals correspond and staff in 12 articles
involved, the perspectives of not only patients and next of kin
but also staff were sought.

Table 2
Codes according to antecedents, attributes and consequences.

IDENTIFIED CODES

Antecedents Attributes Consequences

Loss of power and control Interpersonal factors Self-concept (positive and negative)
A sense of distrust and trust Transformation of consciousness/personal change and empathy Sense of mastery and control
Motivation Self-care, management and recognition of disease Sense of connectedness
Active participation Partnership Independence
Competences Education process Ability to set and reach goals
Intrapersonal resources Participating Development of competencies
Interpersonal resources Aspects such as autonomy and self-determination Quality of life
Transformation of consciousness Personal and subjective process of outcome Responsibility
Social participation Negotiation/dialogue Trust
Patient-centred approach Self-efficacy and self-development Enabling
Support/family support Trust Active participation
Environment

that motivation is the driving force that provides direction and
meaning, and that this antecedent to empowerment operates at
both a conscious and subconscious level. Finfgeld [19] argues that
motivation alone does not guarantee a change in power. Change is
discussed in some of the articles (as an antecedent, attribute and
consequence) and Holmström and Röing [21] and McCarthy and
Freeman [25] argue that the ability to reflect on benefits of
behaviour changes and the willingness to accept change represent
an antecedent to the empowerment process.
3.2.1.3. Participatory relationships, person-centredness, support, trust
and respect. Client participation is considered another essential
prerequisite for empowerment. Castro et al. [23] argue that the
approach towards the patient in empowerment should involve
patient-centredness, and call for a customization of care to
individual needs, desires and circumstances of patients [p.
1926]. Support involves a helpful, warm and supportive
atmosphere from health professionals, family members and
network [24,27] and opportunities for meaningful choices.
1268 K. Halvorsen et al. / Patient Education and Counseling 103 (2020) 1263–1271
Table 3
Overview of descriptive themes in antecedents, attributes and consequences.
Descriptive themes: antecedents Descriptive themes: attributes
Experiencing powerlessness, loss of Being in a process of mutual partnership, reciprocity, trust, respect, participation Enabling a conscious self-understanding and
control and stigma and dialogue to enhance competence
Need of competence Being in an enabling process of change in interaction with others
Experiencing motivation, change and Being in a process of strengthening self-determination
transition
Active participatory relationships
Experiencing (mutual) trust and
respect
Experiencing person-centredness
Experiencing support from others
Mutual trust and respect are an antecedent in several of the studies
[20,21,25,26,28]. Hermansson and Mårtensson [18] describe how
trust, openness and acceptance characterize a nurturing
environment and that meeting patients and users as equals is a
necessary condition in an empowerment process. Another
antecedent is being in active participation [17,18,22–24,26],
which is described as involving mutual commitment to the
process [20]. The ability to participate in an active way in decision-
making and goal setting is emphasized, where contextual factors
like time, choice, trust and care are important [28]. Another theme
within the same area is the experience of person-centredness
involving dialogue and enabling processes [17,18,21,22–26].
3.2.2. Descriptive themes reflecting attributes of empowerment
Attributes indicate the characteristics of the empowerment
process, i.e. after the need for empowerment is elucidated and the
empowerment process is ongoing. Antecedents has some over-
lapping values and properties with the attributes. However, the
difference lay in the process. Distinctive for the terms used in the
attributes are that they all reflect positive laden attributes in
relationships.
3.2.2.1. Process of mutual partnership, reciprocity, trust, respect,
participation and dialogue to enhance competence. Dowling et al.
explain that attributes are often described in a theoretical, and
sometimes in a philosophical, manner [24]. In general, attributes
reflect empowerment as a process. The empowerment process is
described as a social process [20,22], a helping process
[20,21,23,27], and a dynamic process. Furthermore, the
empowerment process is described as an interactive process
[22,28], a transactional process [22] and an enabling process
facilitated in interaction with others [21,23,28]. It is also described
as mutual partnership, trust, respect [27] and partnership in an
educational process [17,20,21,25,26]. For example, Fotoukian et al.
[17] describe how the empowerment process in senior care
involves an allocation of sufficient time for the patient and
significant others, and for the health professionals to surrender
control, as older people know their disease and how it affects them,
but also how they live with the limitations their condition imposes
on them.
3.2.2.2. Change and interaction with others. The empowerment
process involves personal change, self-reflection and
transformation of consciousness [17–21]. Hermansson and
Mårtensson [18] describe that the process starts with an
awareness that makes it possible to start reflecting on the
changing situation. In the empowerment process, knowledge is a
key aspect and a tool to access information; this is connected to the
perception of one’s own knowledge in relation to the situation that
one has to deal with [28]. Attributes of the empowerment process
Descriptive themes: consequences
improved quality of life
Enabling mastery, control, competencies and
goalsetting
A trustful and participatory relationship
focus on strengthening self-care, self-help or self-development
[17,20,21,24,27]. Ntshingila et al. [28] define empowerment as
implying self-belief, trust and self-leadership. Moreover, it implies
an active role in “creating the future of your dreams” [p. 440].
3.2.2.3. Process of strengthening self-determination. Castro et al.
[23] argue that self-determination theory is an underlying theory
of empowerment and that self-determination is a guiding attribute
in the empowerment process. McCarthy and Freeman [25] define
attributes of empowerment as including reciprocal interaction,
autonomy linked to accountability, shared transfer of power and
ultimately greater access to financial and intangible resources such
as knowledge and influence. They argue that empowerment must
be part of a mutual and reciprocal interactive relationship on the
level of individuals, organizations or communities.
3.2.3. Descriptive themes reflecting consequences of empowerment
Consequences are those conditions or changes that arise as a
result of empowerment.
3.2.3.1. Enabling a conscious self-understanding and improved quality of
life. Development of a conscious self-understanding appears in
several of the articles as a central consequence of empowerment [17–
19,21–24,26–28]. A conscious self-understanding is described in
different ways and may involve a positive self-concept [17,20–22,24],
self-esteem [18,26], an integrated self [24], sense of security and
identity [27], and inner strength and a process of transformation
[17,24]. Furthermore, empowerment involves self-development and
self-efficacy [18], increased understanding of oneself, personal power
and self-management [21], hope for the future [26], personal growth,
innersatisfaction[27] andconnectedness [20,24]. Ntshingila etal. [28]
describe empowerment as a consequence when women living with
borderline personality disorder know what is best for them and when
they can take charge of their own lives, by playing an active role in
creating their life and having a feeling of security and connectedness.
Additionally, improved quality of life is described as being a
consequence of empowerment [18,20,23].
3.2.3.2. Enabling mastery, control, competencies and goal setting. A
sense ofmasteryandcontrol isanotherconsequence ofempowerment
[17,18,20,23,24,26,27]. Hermansson and Mårtensson [18] describe
how consequences of empowerment in the midwifery context apply
to both parents and the midwife. For the parents, empowerment
involves being better prepared to tackle new situations and control in
their new life with a baby. For the midwife, a consequence is increased
awareness of parents’ resources and capacity. Other consequences of
empowerment are enabled in competencies, goal setting [19,22,25]
and risk taking [20].
3.2.3.3. Trustful and participatory relationships. Empowerment
includes the development of trust and participatory relationships
 K. Halvorsen et al. / Patient Education and Counseling 103 (2020) 1263–1271
[17,19,24,25]. McCarthy and Freeman [25] describe how
empowerment increases status through the rights and
responsibilities gained through participation in the empowerment
process. They describe the production of trusting, respectful and
nurturing nurse-patient relationships that provide support,
encouragement and information. Nevertheless, they do emphasize
that families must accept responsibility for health choices and
behaviours [25]. Frustration and distress are described as a possible
negative consequence of empowerment [19]. Bennet et al. [22]
underline that one consequence of empowerment may involve being
more conscious of negative self-understanding, e.g. being aware of the
stigma and limitations of epilepsy.
3.3. Analytical themes
In the concept analysis, the descriptive themes involve both
intrapersonal aspects (e.g. loss of control, powerlessness, need of
competence) and interpersonal aspects (e.g. mutual partnership,
interaction, trust, support) of empowerment. However, there is
little description of challenges in the transition of power between
health professionals and the healthcare service user. Thus, equality
in the relationship between health professionals and healthcare
service users is hardly discussed. Accordingly, empowerment
appears as a purpose-oriented action on the terms of health
professionals, instead of a fundamental transition of power, which
is the rationale for empowerment. Thus, when analysing and
synthesizing these articles in detail, we question whether a
paternalistic way of understanding empowerment still prevails,
but in a more implicit way, and whether equality in relations
between health professionals and healthcare service users is still
problematic. To address research question ii, the following two
analytical themes emerged for further discussion.
i User perspective and involvement in empowerment – chal-
lenges of equality in the relationship between the healthcare
service user and health professionals.
ii A present focus on changing users to achieve empowerment
versus an absent focus on power in the relations between the
healthcare service user and health professionals.
The development of trust and participatory relationships is
described in several of the concept analyses as a consequence of
the empowerment process by Fotoukian et al. [17], Finfgeld [19]
and McCarthy and Freeman [25], while Castro et al. [23]
highlight participation as an antecedent. Several of the included
studies refer to the necessity of opportunities for choices and a
trusting, open, accepting and respectful relationship as a
requirement to start an empowerment process [21,25,26,28].
Even so, some of the concept analyses present obvious
challenges in equality between healthcare service users and
health professionals [19,22,27]. For example, several papers
[21–25] describe how patients need competence and knowledge
to make choices on their own behalf, while there is limited
emphasis on health professionals’ need of competence and
attention to power differences in their relationship with
patients. Additionally, our argument is based on the impression
that empowerment is described in the concept analyses as a
recipe of acknowledgment and attentiveness with limited
discussion of challenges that follow from the ideals of
empowerment in healthcare. It seems that nurses or other
health professionals are supposed to create an empowerment
process in the patient relationship with the rationality of
making patients act differently, thus changing the patient. The
empowerment process occurs as more of a ‘helping process’
from the health professional than a mutual process between the
parties.
1269
4. Discussion
In this thematic synthesis, we aimed to explore how the
healthcare service user perspective is apparent in concept analyses
of empowerment and in particular, how user participation occurs
in the empowerment process. We found that the user perspective
and involvement in empowerment implied challenges of equality
in the relationship between the healthcare service user and health
professionals, and that the question of power was scarcely
discussed.
Empowerment is revealed in the concept analyses as being
given by health professionals rather than taken by healthcare
service users, as also discussed by VanderPlaat [12]. Thus, the
empowerment process tends to be more like a behaviour change
approach, and is paternalistic in showing little regard for the
individual’s own perceptions, as also argued by Tengland [13]. The
authors of the included articles only to a limited extent discuss the
obvious power relations in empowerment, which challenge
equality between the parties, as also discussed in a more recent
systematic review by Agner and Braun [29]. We will argue that lack
of awareness to inequality and paternalism in the relationship
between health professionals and the health care service user may
lead to a judgmental attitude and is a crucial barrier to
empowerment.
User participation is an important theme across the included
studies, as additionally emphasized in other studies [9,17–28,32].
Moreover, participation is a growing discourse in health policy
documents globally [4,5,30] and during the last three decades, the
goal has been to change the role of the healthcare service user from
a passive receiver to an active partner [30–32]. Nevertheless,
research highlights that healthcare service users experience
limited user participation in relationships with health professio-
nals [33–35]. In addition, Agner and Braun [29] demonstrate that
healthcare service users frequently experience superficial involve-
ment in decision-making as powerlessness and loss of freedom.
Some of the patients in their included studies described not being
able to participate in their own health choices as a form of coercion,
while others had not even realized that involvement in decisions
was an option in a hierarchical healthcare system [29]. Despite
this, only two of the studies in our review [19,22] revealed
challenges and questions of power and inequality in the relations
between health professionals and healthcare service users. In these
two studies, epilepsy and COPD were related to experiences of
stigmatization. These studies show that power is difficult to
redistribute and that certain groups are particularly vulnerable to
oppression. Patients who are chronically ill and depend on health
services on a regular basis are especially vulnerable [34,35].
Moreover, these user groups are probably the ones who would
benefit the most from equality rather than paternalism in the
services. This might be compared to the findings of Agner and
Braun [29], who describe how a lack of control and participation
was strongly felt by mental health patients. This concurs with the
results from a study by Tveiten et al. [35] that aimed to understand
patient experiences of empowerment in a psychiatric context. The
extensive use of empowerment made Kuokkanen and Leino-Kilpi
[7] warn against a broad and sweeping use of the concept that
undermined its value. Our findings support this concern.
All our included articles elaborated the concept of empower-
ment in the perspective of the relationship between the healthcare
service user and the healthcare provider in different contexts and
with different groups of patients. However, only two of the concept
analyses were based on the authors’ own empirical work, studying
empowerment within a specific user group and context [19,19].
Despite this, the authors’ conceptualization of what the concept of
empowerment implied within these groups did not differ
significantly. Rivest and Moreau [36] claim that not studying
1270 K. Halvorsen et al. / Patient Education and Counseling 103 (2020) 1263–1271
empowerment in its context is an important criticism of studies of
empowerment. Thus, there is a danger of using empowerment
discourses to “legitimatize practices that are not at their core based
on an empowerment approach” [36]. We would also argue that
there is a great risk of understanding the concept of empowerment
in a generalized way without involving and approaching specific
groups of healthcare service users. All healthcare providers should
be careful not to draw conclusions about an overall understanding
of empowerment for different user groups in diverse contexts.
4.1. Study limitations
The primary aim of synthesizing qualitative research is to
address questions about people’s perspectives and experiences in
complex and contested territory, which may also inform health
policies and practices [15]. There are some weaknesses in this
thematic synthesis. Firstly, the quality of the concept analyses
varied, which made the critical appraisal problematic, since no
accurate quality appraisal tool exists for concept analyses. Some
articles were included, despite lower quality, as they represented
the most read and cited concept analyses of empowerment in the
last two decades. Another challenge was that the selected articles
mainly focused on the approach of the concept analysis, rather
than the methods of searching and reviewing the literature.
Furthermore, in the critical appraisal it became clear that the
descriptions and methodological quality have improved in the
most recent concept analyses. Additionally, the term empower-
ment is complex, which may have led to exclusion of relevant
search words. However, the methodological transparency
strengthened the validity of this synthesis. In a thematic synthesis,
the choice of analytical themes is subjective, as they develop from
what captures the researchers’ attention and interpretation [15], as
also underlined by Agner and Braun [29]. As a large group of
authors, we conducted extensive discussions to strengthen the
study. A final question is whether concept analyses can be subject
to synthesis. We would claim that they can, and that this is
important. Empowerment is a growing concept in healthcare,
which necessitates a broad understanding and continuous critical
discussion.
5. Conclusion
In concept analysis of empowerment, the concept is found to be
in a contradictory position between the user perspective and the
goalsetting of the healthcare personnel, where the user perspec-
tive often seem limited. There is a broad use of characteristics of
what the concept includes in healthcare settings. However, a
paternalistic and helping undertone characterizes how to ap-
proach empowerment in relations with healthcare service users.
The number of healthcare service users with complex needs is
increasing; health professionals need education regarding what to
can empower such users from their own perspectives, in order to
provide high-quality care.
5.1. Practice implications
A synthesis of concept analyses of empowerment may provide a
broader understanding of empowerment across individuals, user
groups, cultures and contexts. Everyday empowering clinical
practice is contextual and realized through an emphasis on user
perspectives and equality in power relations. Knowledge and
awareness of empowerment processes between healthcare service
users and health professionals based on equality, trust and respect
is crucial within the healthcare service to avoid judgmental
attitudes and paternalism. We would argue the need for more
context-driven research and practice-oriented theories of
empowerment to improve empowerment in clinical practice.
Health professionals need education regarding users developing
health competence. It is a matter of concern if researchers neglect
the user perspective and instead develop grand theories that lack
nuances relevant to particular user groups and contexts.
Funding
Funded with NOK 150.000 from Oslo Metropolitan University,
Faculty of Health Sciences, Norway.
Authors’ contributions
KH and AD designed and led the project. KH, AD, CH, MN read all
abstracts and decided on full-text reading. All authors read and
discussed all included articles. All authors participated in analysis
of the included studies and in writing the manuscript. All authors
read the final version of the manuscript.
Declaration of Competing Interest
There are no conflicts of interest.
Acknowledgement
Thanks to OsloMet, Faculty of Health Science for funding this
work. Thank you to the Library at OsloMet for always good
guidance.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in
the online version, at https://doi.org/10.1016/j.pec.2020.02.017.
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