Clinical

Self-empowerment in health
promotion: a realistic target?
Nici Mackintosh
There have heen
many calls for nurses
to adopt a
self-empowerment
model for health
promotion practice
rather than
continuing to work
from the medical
model. Continuing
with our series on
health promotion,
this article examines
features of the
self-empowerment
approach and
questions whether
its goals are
achievahle.

4lh he term 'health promotion' is 'very

difficult to pin down for descriptive purJLh((Beattie, 1991). In this article, it is
poses'
accepted that health promotion includes:
'...both health education and all attempts
to produce environmental and legislative
change conducive to good health'
(Dennis et al, 1982).
While health promotion involves the alternative and complementary processes of
social engineering and health education,
the latter is about facilitating health
choices:
'Health education is concerned with
raising individuals' competence and
knowledge about health and illness,
about the body and its functions, about
prevention and coping; with raising
competence and knowledge to use the
health-care system and to understand its
functions; and with raising awareness
about social, political and environmental
factors that influence health*
(Baric, 1985).

Strategies for health education

Nici Mackintosh is Senior

Clinical Nurse at Sandwell
Healthcare NHS Trust,
West Midlands

Health education takes different

approaches. In an effort to examine the
practical implications and goals for each
strategy, many authors have attempted to
devise classifications for these approaches
(e.g. Tones. 1981, 1986; Beattie, 1982,
1991). Five classifications for such
approaches can be identified {Table 1).
Research studies (Johnston, 1988; Latter
et al, 1992; Mackintosh, 1993) have confirmed that the majority of nurses persist
with the behavioural change approach.
Gott and O'Brien (1990) place responsibility for this situation on individualistic ideologies and limited health promotion
programmes and policies for health in
nursing which emphasise frameworks of
individualistic action at the expense of collective nursing philosophies.

British Journal of Nursing, 1995. Vol 4, No 21

Critics of the behavioural change model

point out that it assumes that lay people
believe the 'experts' know best. The model
imposes medical values on the individual
and may also impose feelings of guilt if the
client chooses nor to follow the regime.
Moreover, in terms of a violation of
respect for the individual's autonomy,
there are ethical objections to its assumption that professionals have the right
to decide what constitutes 'healthy
behaviour'.
Both the behavioural change and educational approaches embrace the existential
belief that;
'People are born free and create
themselves by means of their decisions
and choices' (Jacob, 1994).
Individuals are perceived as free to choose
a course of action and are therefore considered responsible for their health. This
individualistic concept of health has been
strongly criticized as it fails to take adequate account of the social and economic
determinants of ill-health and healthrelated behaviour outside an individual's
control.
The social action approach views human
nature from the determinist perspective.
Determinists believe that a person's freedom is limited by biological, psychological
and social forces. These cause factors such
as race, gender, social class and genetics to
become the determinants of health. This
strategy not only addresses the fundamental social issues underlying disadvantage
and ill-health, but also can be regarded as
coercive for it seeks to perpetuate a particular political view of society (Tones,
1986).
Furthermore, it seems naive to place
total responsibility for health on the state.
Whereas the government has a duty to create facilities for health, it is still up to the
individual to act upon information in a

1273

Self-empowerment in health promotion: a realistic target?

Table I. Strategic approaches for health education
Behaviour change (preventive
or traditional approach)

Focus: the individual

Goal: to persuade the individual to adopt a particular lifestyle/adhere to
medical advice to prevent/limit disease and reduce mortality/morbidity rates
Rationale: curative medicine cannot cope with current rate of disease.
Prevention better/cheaper than cure
Evaluation: measured on whether or not the individual adopts a particular
lifestyle or changes his/her behaviour
Example: advising/persuading the individual to give up smoking

Educational approach

Focus: the individual

Goal: to help the individual develop his/her knowledge and skills and
explore his/her attitudes, so that he/she can make an informed choice about
his/her health
Rationale: education is about rationality and freedom of choice
Evaluation: measured on the facilitation of decision-making, irrespective of
the nature of the decision actually made
Example; presenting the individual with the facts about smoking and leaving
the individual to make a choice

Social action, radical, social

change approach

Focus: the environment at societal level

Goal: to make healthy choices the easy choices by changing the physical
and social environment so that individuals are enabled to adopt healthy
behaviour. Also aim to raise individuals' awareness and involvement in health
issues in order to stimulate the demand for social change
Rationale: the root of health problems lies in social, economic and political
factors
Evaluation: measured on the implementation of critical consciousnessraising, and/or social, political or environmental change conducive to health
Example: campaigning for smoke-free areas, lobbying parliament for an
advertising ban on tobacco

Self-empowerment,
humanistic approach

Focus: the individual

Goal: to facilitate decision-making by modifying the individual's
self-concept and enhancing self-esteem
Rationale: by developing motivation, setf-confidence and skills, the
individual is in a better position to identify his/her own health needs and take
action to meet them
Evaluation: measured on the acquisition of life skills and decision-making
skills
Example: enabling the individual to identify why he/she smokes, helping the
individual to develop the confidence and skills needed to make a choice and
implement a health plan

Community development
approach

Focus: a group
Goal: to help a group work together, find its common interests and
fight its particular health cause
Rationale: it is better to work from the group's valuable experiences
rather than to work from a professionally defined agenda
Evaluation: measured by successful public awareness raising of the group's
concerns and the implementation of health action for the benefit of the group
Example: identifying a need for a self-help group, facilitating the group, acting
as resource and supporter for the group

1274

Brlti5h Journal of Nursing, 1995, Vol 4. No 21

Self-empowerment in health promotion: a realistic target?

^Within the
hospital setting it
is often much
harder to
empower the
individual
because of the
nature of the
institution itself.
However^ on a
smaller scale, the
nature ofpersonal
interactions
between nurse
and patient can
play an important
part.'

way that he/she thinks best. A social

action strategy may fail to provide the
individual with the motivation to internalize the values it promotes or to promote
autonomous self-care.
An approach involving the pursuit of
self-empowerment facilitates informed
choices which are so hard to achieve with
the educational approach. A self-empowerment strategy aims to:
Promote beliefs and attitudes
favourable to deferring immediate
reward for more substantial future
benefit
Increase internal control and selfesteem and develop social skills,
e.g. assertiveness (Tones, 1981)
Thus, the onus is on the individual, but
because the self-empowerment strategy
aims to help learners become more selfassertive, tbe individual is able to develop
a notion of being in control. A selfempowered person is better able to resist
pressures to smoke (Tones, 1986) and has
more understanding and control over
social, economic and political forces.
The community development approach
shares many features of the self-empowerment approach, but it is on a larger scale.
Whereas the self-empowerment approach
is limited to developing the individual's
ability to deal with social injustices, the
community development approach allows
certain groups to work together to fight
for their health needs.
*If nursing is to take health promotion
seriously it must be actively concerned
with the empowerment of clients and
patients' (Tones, 1993).
Recognition of the criticisms levelled at
the behavioural change model, together
with recent interest in holistic and clientcentred nursing, has resulted in a change
of focus in health promotion in nursing
towards the theory of self-empowerment.

Theory of self-empowerment
There are four factors which Tones (1993)
considers central to the concept of
empowered action for the individual:
1. The environmental circumstances
which may either facilitate the exercise
of control or, conversely, present a barrier to free action
2. The extent to which individuals actually
possess competencies and skills which
enable them to control some aspects of
their lives, and perhaps overcome environmental barriers
British Journal o( Nursing, 1995. Vol 4, No 21

3. The extent to wbich individuals believe

themselves to be in control
4. Various emotional states or traits which
typically accompany different beliefs
about control such as feelings of
helplessness and depression, or feelings
of self-worth.
One of the criticisms against the educational approach is that the mere understanding of a health issue is not enough to
precipitate health action. The provision of
information needs to be accompanied by
processes of belief and the clarification of
values, followed by some practice in decision-making usually in a simulated setting. For self-empowerment to occur, a
developmental programme is required,
aimed at certain aspects of personal
growth. Two important personality characteristics central to this process are selfesteem and locus of control (Tones, 1986).
Self-empowerment in practice
Many nurses concerned with community
development are involved in empowering
both individuals and groups. The agenda is
frequently set by individuals within the
community rather than by the professionals, and the role of the nurse is not that of
an expert, but of a facilitator and partner.
For example, the school nurse may
respond to teenagers' requests to run a
workshop on coping with the problem of
peer pressure to experiment with drugs, or
a practice nurse may set up a self-help
group to help individuals deal with stress.
Igoe (1993) and Walker (1993) provide
further examples of community settings
with the potential for self-empowerment
strategies.
Within the hospital setting it is often
much harder to empower the individual
because of the nature of the institution
itself. However, on a smaller scale, the
nature of personal interactions between
nurse and patient can play an important
part. By respecting the individual's wishes
and allowing the patient the right to
choose, the likelihood of disempowering
the mdividual is minimized. Believing that
one has some kind of control over one's
life is beneficial in many ways (Tones,
1993). However, merely having the belief
that one is in control is not generally sufficient for the empowerment process to
begin; the individual must also be provided with the competencies needed to
achieve his/her goals.
Wilson-Barnett (1993) noted that
enabling people to maximize their individ-

1275

Self-empowerment in health promotion: a realistic target?

How many
nurses are in a
position to give
adequate quality
time and privacy,
in a suitable
erivironmenty to
enable the
personal
development of a
patieritf Nurses
ofteii take on tbe
role of Jianied
nurse for a
number of
patients and are
unable, due to
lack of contact
time, to build up
the deptb of
relationship
necessary to
develop patients'
life-skills and
potential for
managing tbeir
own health.

ual potential should be the aim of many

.\j;encies (statutory and voluntary) and
'health professionals may be in a special
situation lo influence this'. But are nurses
in a position to facilitate patients' personal
j^rowth? In order to examine this question,
the location of the empowerment process
withm the context of the counselhng relationship must be established.
Person-centred counselling
It is possible to draw a parallel conclusion
between certain characteristics of the person-centred counselling relationship of the
client and counsellor and the relationship
established in a self-empowerment strategy. Person-centred counselling places
high value on the individual's experiences
and the importance of the individual's
subjective perceptions of reality. It challenges each person to accept responsibility
for his/her own life, and to trust the irmer
resources available to all those who are
prepared to develop self-awareness and
self-acceptance.
The notions of self-empowerment and
person-centred counselling both fit into
the category of a 'helping relationship*, as
defined by Rogers (1967):
'A helping relationship is one in which at
least one of the parties has the intent of
promoting the growth, development,
maturity, improved futictioning, and
improved coping with life of the other.'
They also emphasize the importance of
unleashing the power that lies within the
individual rather than relying on the
authority of the expert.

Table 2. People involved in

health promotion
Town-planners
Agriculturalists
Industrialists and businessmen
Politicians
Those involved with communication
and mass media
Environmental health workers
Directors of transport services
Educationalists and social workers
Medical and heatth-care
professionals
Source: Tones (1966)

1276

It therefore follows that many of the

conditions necessary for the development
of a therapeutic relationship between
counsellor and client may also be required
to foster a growth-conducive climate
between patient and health-promoter.
However, on closer examination, the fulfilment of these conditions is likely to be
seen as problematic within certain fields
of nursing.
First, how many nurses are in a position
to:
Be genuine?
Offer unconditional positive regard and
total acceptance?
Feel and communicate a deep empathic
understanding towards the patient?
Yet the counsellor must demonstrate these
qualities in order to facilitate the personal
growth of the client (Rogers, 1967).
Second, the client voluntarily chooses to
form a relationship with the counsellor.
The patient, on the other hand, is often
forced to form some kind of relationship
with the nurse. There is still the element of
choice as to what form this relationship
should take, but he/she may may not wish
to take responsibility for his/her
own health.
How many nurses are in a position to
give adequate quality time and privacy, in
a suitable environment, to enable the personal development of a patient? Nurses
often take on the role of named nurse for a
number of patients and are unable, due to
lack of contact time, to build up the depth
of relationship necessary to develop
patients' life-skills and potential for managing their own health
Thus, we need to question the feasibility
of setting self-empowerment as a goal for
nursing practice. It is questionable
whether the majority of nurses are in a
sufficiently credible and empowered position themselves to be able to facilitate selfdiscovery in others. How many nurses
have access to support networks and
opportunities for guidance from qualified
experts to deal with emotionally threatenmg situations?
There is an additional problem for those
nurses working within the hospital structure. The management of health and welfare issues has traditionally been placed in
the hands of experts, located within large,
centralized bureaucracies. In a system that
calls for dominance by professionals, it is
difficult to achieve egalitarian working
relationships. A call for actively participative roles for patients challenges the existBritish Journal of Nursing. 1995. Vol 4, No 21

Self-empowerment in health promotion: a realistic target?

ing power/control base (Kcyzcr, 1988).
There is the added danger that, in an
attempt to adopt a facilitative approach,
activities which arc, in reality, manipulative and defined by the nurse's agenda can
be labelled as participative.
Similarly, many of the measures for evaluation of health promotion success
within both community and hospital settings are still defined by the behavioural
change approach. It is hard for nurses to
work within a model of self-empowerment
when their work is often evaluated
by compliance rates and evidence of
'positive' changes in lifestyle (Mackintosh,
1996).
There is also a danger that nurses will
focus on those patients who are receptive
to and at ease with the notion of taking
control for themselves. These patients
are likely to be in the higher social
classes. In effect, this actually perpetuates
social inequality and maintains the
status quo:
'...the greatest beneficiaries being those
who are already well able to cater for
their own health needs, and who have
the power and social influence to change
things further to their own advantage'
(Campbell, 1993).
The definition of self-empowerment also
involves the facilitation of some exercise of
control over the environment. It is questionable how many nurses are in a position
to do this.

KEY POINTS
There are three individualistic health education approaches:
behaviour change; educational; and self-empowerment.
Traditionally, the focus in health education in nursing has
been one of behavioural change.
More recently, many authors have advocated a move towards
a self-empowerment approach for nursing.
Due to the constraints of the working environment and
nurses' lack of skills, it is often unrealistic to expect the
majority of nurses to be in a position to empower and
faciiitate the personal growth of a patient.
It is important to acknowledge that nurses are in an important
position as providers of information, not as indoctrinators or
advisors, but as carers.
Nurses have a duty to acknowledge the social structural facet
of health.

British Journal of Nursing. 1995, Vol 4, No 21

Setting new targets

It is important not to lose sight of the. fact
that the list of those involved in health
promotion is extensive {Table 2). Once it
is acknowledged that health professionals
actually play a relatively marginal role in
health promotion within the wider context
of public health, it may be easier for
nurses to re-cvaluate the aims of their
practice. After all:
'Health promotion must use a wide
variety of complementary strategies'
(World Health Organization, 1984).
All health education strategies should be
recognized as having their own degree of
importance, since health can only be promoted in society when an amalgam of different approaches are applied.
Therefore, the aims of health promotion
practice for nurses should be:
To strive for unconditional acceptance
of the health values of individuals
To show consideration of the environmental and social factors affecting
individuals
To offer health information which should
not take the form of indoctrination,
advice, or persuasion. Nurses need to be
aware that it is almost impossible to give
information that is totally devoid of value
judgments. Thus, nurses need to develop
their communication skills and examine
their position as providers of information.
Health promotion practice for nurses
should therefore take the form of:
Valuing individuals and their health
beliefs
Showing sensitivity to the environmental, social and economic factors affecting the health status of individuals
Providing health information
Constantly evaluating and reviewing
the accuracy of available health information
Raising individuals' awareness of the
social, economic and environmental
determinants of health
Informing individuals of their rights,
and how to access other services
Involving individuals in decision-making whenever possible
Offering support to individuals by
mobilizing appropriate resources and
liaising with appropriate professionals
Respecting individuals' rights to choose
their own courses of action for health
Uniting with other nurses to ensure
that professional bodies lobby for good
public health poUcies.

1277

Self-enipowerinent in health promotion: a realistic target?

Conclusion
Whereas those nurses who are in a position to facilitate personal growth in
patients should be encouraged to do so, it
is important not to exclude those who are
not. Therefore, all nurses should be
encouraged to assess their roles as carers,
and to review their relationships with
patients from the perspective of their
potentially powerful positions as health
professionals and information-givers. In
this way, nurses can use approaches which
take note of social structure factors while
focusing on individuals' needs and their
personal resources.
Baric L (1985) The meaning of words: health promotion.; Inst Health EdHc2ii\): 367-72
Beattie A (1982) Changmg Codes of Health. Seminar
Notes. Institute of Education, University of
London
Beattie A (1991) Knowledge and control in health
promotion: a test case for social policy and social
theory. In: Gabe J, Calnan M, Bury M. eds. The
Sociology of the Health Service. Routledge,
London: 162-202
Dennis J, Draper P, Holland S, Shipster P, Speller V
and Suntcr I (1982) Health Promotion in the
Reorganised NHS. Unit for Study of Health
Policy, London
Campbell A (1993) The ethics of health education.
In: Wilson-Barnett J, Macleod-Clark J, eds.
Research in Health Promotion and Nursing.
Macmillan Press, Hampshire: 2-8
Gott M, O'Brien M (1990) The role of the nurse in
health promotion. Health Promotion Int 5(2):
373
Igoe J (1993) Healthier children through empowerment. In: Wilson-Barnett J, Macleod-Clark J, eds.
Research in Health Promotion and Nursing.
Macmillan Press, Hampshire: 145-53

Jacob F (1994) Ethics in health promotion: freedom

or determinism? BrJ Nurs 3(6): 299-302
Johnston I (1988) A study of the promotion of
healthy lifestyles by hospital based staff.
Unpublished MSc thesis, University of
Birmingham
KeyZL-r D (1988) Challenging role boundaries: conceptual frameworks for understanding the conflict
arising from the implementation o t t h e nursing
process in practice. In: White R, ed. Political Issues
in Nursing: Past, Present and Future. Vol 3. Wiley
and Sons, Chichester, 95-119
Latter S, Macleod-Clark J, Wiison-Barnett J, Mabin J
(1992) Health education in nursing: perceptions of
practice in acute settings./-4(/i;M<r5 17(1): 164-72
Mackintosh N (1993) Nurses and their role in health
promotion: inconsistencies between theory and
practice? Unpublished MSc thesis. University of
Central England in Birmingham
Mackintosh N (1996) Promoting health: an issue for
nurses. Quay Books, Mark Allen Publishing,
Dinton (in press)
Rogers C (1967) On Becoming a Person: A
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Cornpany, London: 39-57
Tones B (1981) Health education: prevention or subversion?/ Soc//e^/f/j/101; 114-17
Tones B (1986) Health education and the ideology of
health promotion: a review of alternative
approaches. Health Editc Res 1(1): 3-12
Tones B (1993) The theory of health promotion:
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Macleod-Clark J, eds. Research in Health
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Hampshire: 3-12
Walker J (1993) A social behavioural approach to
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Wilson-Barnett (1993) The meaning of health promotion: a personal view. In: Wnson-Barnett J,
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Europe News 3: 1-6

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