Letter to the Editor

Abstract

With respect to the article ‘Empowerment: what about the evidence?’, the leader, ‘The dotted line’, and your comments about these articles, Practical Diabetes International 2000; 17 (3), I offer the following comments. Empowerment, in the sense of consideration for the whole person and shared governance, is not a new concept. In fact it has been a basic tenet of health care from the time of Hippocrates, who is reputed to have said, ‘In order to cure the human body it is necessary to have knowledge of the whole’. The current ‘empowerment model’ is a re-emergence of the original blend of ‘art and science’ of early health care models – a concept now know as holistic care. Neither the biomedical model, nor the empowerment model as discussed by Skinner and Cradock, takes account of the physical and environmental factors that enable people to be ‘empowered’. It is difficult for people to take control and actively make decisions if they are physically unwell due to metabolic imbalances, or where mere survival is a struggle and diabetes supplies are not available, as is the case in many of the world's communities. Basic survival needs must be met, in order for people to focus on their health. The biomedical model is criticised for having little regard for emotional and spiritual issues. The empowerment model is seen to disregard the contribution of the biomedical model. Such thinking is divisive and counterproductive and disempowers health professionals. Together, as Professor Shaw rightly points out, science and art (empowerment) constitute holistic care that has a better chance of meeting an individual's needs. The essential element for diabetes is balance, which applies to individual factors and the approach to diabetes care. Balance between an individual's physical, mental, spiritual and cultural aspects is necessary in order to achieve good clinical outcomes in quality of life. The important issue in achieving balance is the establishment of a therapeutic partnership between the health professional and the individual. Under the empowerment model the health professional accepts the legitimacy of the individual's goals, even if these goals result in sub-optimal metabolic control. The individual must be prepared to share responsibility for the outcomes and to accept the consequences of his or her actions. Most discussions about empowerment and patient-focused care concentrate on the individual's right and goals. Few mention responsibilities. In the guise of devil's advocate, I pose three questions. Can we truly deliver an empowerment model, considering the constraints on care that currently exist in most countries – lack of time, resources, money and practitioner skill? Can we ever fully inform another person? A large amount of diabetes information, and misinformation, is widely available and people are often confused about their choices. Can any health system afford the consequences of empowered decisions where people choose to ignore advice and settle for less than optimal control? As health professionals we spend a lot of time discussing patient behaviours and how to change them. It is time to look at ourselves. Time we incorporated reflective practice into whatever care model is used and examined our own behaviours, beliefs and attitudes, before we explore those of the people we care for. We need to ask ourselves whether we are giving conflicting messages by our example and body language. After all, verbal communication represents less than 50% of the consultation. Finally, in some circles the word ‘empowerment’ is falling into disrepute and ‘enabling’ is emerging as the new buzzword as advertisers and other frivolous word artists seize the phrase. It could be that both words have an element of condescension. It may be that orthodox medical and nursing management can learn a lot from complementary therapy models. Trisha Dunning*