Yan PENG, Lin HAN, Fang-Fang AN, Li LI,Yue-Li HOUDepartment of Nursing, School of Nursing, Shaanxi University of Chinese Medicine, Xianyang, China; Department of Nursing Administration, Affiliated Hospital of Shaanxi University of Chinese Medicine, Xianyang, China

ABSTRACT

Empowerment education aims to stimulate the intrinsic motivation of patients and make them pay more attention to their own health so as to control the disease. This paper expounds the concept, theoretical framework, implementer, object, implementation steps, forms, and evaluation methods of empowerment education for cancer patients, in order to provide practical guidance for clinical workers.

Keywords: Cancer, empowerment education, health education, health education

INTRODUCTION

With the growth of the world population and the aging of the population, the incidence and mortality of tumors are also increasing rapidly.[1]Tumors have become one of the major public problems threatening the health of the population.With advances in medical technology, cancer patients can also achieve long-term survival, and more and more cancer diseases have been included in the category of chronic diseases. Therefore, oncology is also following the pattern of other chronic diseases to study patients’ self-management level, gradually realizing the importance of patient autonomy,and trying to give patients the right of disease management.[2]

The concept of empowerment originated in the “social movement”, which was an attempt to increase the autonomy and rights of oppressed groups.[3,4]With the continuous development and enrichment of this concept, its meanings are diversified in different disciplines. The most frequently cited definition of empowerment in the health field is to help patients discover and develop the intrinsic drive to take responsibility for their own lives.[5]In 1986, the World Health Organization identified empowerment as one of the three strategies for health promotion and defined it as a process through which people gain greater control over behaviors and decisions that affect their health.[6]In the study of Groenetal.,[7]five characteristics of the concept of empowerment for cancer patients were described. The first is being autonomous and respected. Being autonomous means that patients can make choices and make decisions about their health or life goals. Being respected requires that medical workers share knowledge and resources in such a way that patients feel fully recognized. The second is that patients have knowledge about their disease, about themselves, and about available supporting resources to enable themselves to make more informed decisions. The third is to develop or strengthen skills that make the current situation positive, such as motivation to pursue health goals, optimism, and effective collaboration and interaction with health-care workers. That is a sign of empowering intervention. The fourth attribute is having a strong enough source of social support so that patients can perceive support from community, family, and friends. The fifth is to maintain a sense of self-worth by going back to work and/or contributing to family and friends.

Cancer patients often feel powerless because they lose control of their health and life, which can have a negative impact on their recovery and reconstruction of normal life. Therefore, gaining the ability to control life, namely empowerment, is one of the challenges faced by cancer patients. In fact, patient empowerment begins with access to information and health education.[8]This paper intends to review the research progress of empowerment education in the health education of cancer patients in order to provide reference for the relevant research and clinical nursing work.

AN OVERVIEW OF EMPOWERING EDUCATION

Empowerment education is a new and effective health education model, which can enhance people’s belief to change their unhealthy life behavior. The American Diabetes Association defines empowerment education as a new model of health education centered on self-health management,which aims to control disease by stimulating patients’ internal motivation and making them pay more attention to their own health.[9]This mode of education changes the status quo of the traditional health education in which patients obey the medical staff passively, and it emphasizes on being dominated by educational objects. The health educator plays a role of a collaborator who is asked to establish an equal and cooperative relationship with the education object, provide information and support according to the needs of the education object, stimulate the subjective initiative of health management, make self-decision, assume the responsibility of self-management, and improve the self-efficacy, thus enabling patients to improve the ability to protect themselves based on the definition of personal health.[10,11]

THE THEORETICAL FRAMEWORK OF EMPOWERMENT EDUCATION

The theory of empowerment education is based on self-determination and autonomy support theories.Self-determination theory emphasizes that individuals are more likely to promote their own potential development and learn relevant skills in order to pursue goals in the face of problems that they consider important.[12]Autonomy is an important part running through it. The purpose of authorized education is to make patients clear about their own problems, proactively engage in behaviors that contribute to the development of the disease, give full play to their subjective initiative, and assume full responsibility for the self-management of the disease.[13]Autonomy support means that doctors, nurses, and social supporters should avoid controlling patients’ behaviors but provide meaningful self-management choices and relevant information after fully understanding patients’ feelings and needs.[14]Autonomy support theory also recognizes patients’ right to self-management of the disease. It is the responsibility of the implementer of empowerment education to respect the patient’s choice, provide the patient with the appropriate information, technology, and support, and assist the patient to make the right decision.

THE IMPLEMENTER AND EDUCATION OBJECT OF EMPOWERMENT EDUCATION FOR CANCER PATIENTS

In relevant studies in China, primary nurses or oncology special nurses are mainly responsible for the implementation of empowerment education. The specific staffing requirements are roughly the same, that is, having intermediate or above professional titles, working experience in clinical work for more than 5 years, solid theoretical foundation, and good communication skills.[15,16]In a few studies, doctors and psychological counselors also participated in the empowerment education of cancer patients, providing more professional health and psychological counseling.[17]In foreign countries, the implementers of empowerment education for cancer patients have diversified characteristics.In addition to professionals in medical institutions, some patients with similar experiences form self-help groups to share useful health information and obtain emotional support, which can also improve their empowerment level and living quality.[18]Or a team composed of peers and community volunteers after training to give guidance to other community members suffering from cancer has also been proved to be helpful to improve patients’ health knowledge level, encourage the change of bad behaviors,and stimulate the educated cancer community members to become peer educators.[19]

In recent years, the education object of empowerment education is no longer limited to patients, but also extended to healthy people, in order to achieve the purpose of popularizing health knowledge, establishing health beliefs,and correcting bad behaviors. Family caregivers of cancer patients often bear important care responsibilities, and their care ability directly affects the patients’ quality of life and rehabilitation effect. Implementing authorized education for family caregivers can help them acquire disease nursing knowledge and related nursing skills, and quickly adapt to the role change as caregivers, thus improving the quality of care.[20]

IMPLEMENTATION STEPS OF EMPOWERMENT EDUCATION FOR CANCER PATIENTS

At present, the most widely used and mature implementation steps of empowerment education are defining problems,expressing emotions, setting goals, making plans, and evaluating effects.[18]

The first step is defining problems, that is, to preliminarily assess the educational needs and existing problems of patients. There are two approaches: (1) retrospection: to avoid the unwillingness of the patient to express himself,educators review the patient’s case and proactively identify problems; (2) interview: educators use open-ended questions and guided language to understand patients’ needs and main problems. The second step is expressing emotions. On the basis of gaining the trust of patients, educators should encourage them to express their psychological feelings, allow them to vent their bad emotions, and help them relieve their psychological burden and eliminate bad emotions. The third step is setting goals. When setting goals, patients should take the lead. Short-term and long-term goals should be set according to specific conditions, and each goal should be specific and feasible. The fourth step is making plans.At this stage, the educator should ask the patient what he/she intends to do and provide professional advice, so as to reach a consensus through consultation with the patient.In the meantime, educators should continue to encourage patients to carry out as planned and take responsibility for self-management. The fifth step is evaluating effects.Educators should assist patients to complete self-evaluation,give affirmation and encouragement to the phased results achieved, and summarize experience. In the implementation steps of empowerment education, the educator only plays the role of guidance and assistance to encourage patients to participate in health management and enhance their internal health awareness and sense of control over their health.

FORMS OF EMPOWERMENT EDUCATION FOR CANCER PATIENTS

Online network empowerment education

With the rapid development of modern technology and the era of big data and artificial intelligence, more and more patients are willing to use the internet to get the latest information on different aspects of their diseases. The development of some internet-based tools that can provide medical information and create patient communities has been a hot topic. Many studies have confirmed that such tools can meet patients’ educational needs and promote patient empowerment.[21,22]In China, instant messaging software such as WeChat and QQ is the main platform for clinical nurses to implement network empowerment education intervention for cancer patients. Such software is widely accessible, easy to operate, and has strong privacy, effectively promoting zero-distance communication between nurses and patients.There are more forms of related network empowerment tools in foreign countries, such as “when 2 go” website specially used for elderly lung cancer patients with low education level and low health literacy, interactive video game designed for tumor children,[23]LucAPP used for real-time monitoring and management of symptoms of lung cancer patients,[24]and so on. Applying these tools to the nursing process of cancer patients shows that they can improve the self-management ability of patients and reduce their anxiety, depression, and other bad emotions.

Offline face-to-face empowerment education

There are various forms of offline face-to-face empowerment intervention, such as one-to-one interview, group discussion,peer education, workshop, and so on. In China, the intervention sites of empowerment education are relatively limited, most of which are one-to-one education for patients in hospitals, while foreign researchers will join patients’relevant organizations or enter communities and families for various forms of health education. Stang and Mittelmark[25]initiated a participative intervention study of newly diagnosed breast cancer patients, namely to create three professionally led self-help groups of 5–7 people, each in turn holding a weekly round table meeting lasting about 90 min in the meeting room of the Norwegian Cancer Society. In the meeting, the main topics that the patients think are important,such as treatment, rehabilitation, and daily life status, which are discussed with each other to improve the understanding of their own advantages and promote learning from the other person’s response. German researchers, Schmidtet al.[26]provided a knowledge manual of operation, anesthesia and perioperative management compiled by multidisciplinary experts to the elderly cancer patients who received surgery,which started from the date before surgery, guided patients to record their own pain, activity and nutrition in the form of a diary, encouraged patients to ask questions about recovery and discharge, conducted patient empowerment and effectively improved the nursing quality of patients with postoperative pain. The research team of Kinneyetal.[27]provided a 12-week empowerment education for breast cancer patients, focusing on relaxation techniques, meditation practices, and disease education, which improved the quality of life of the patients. The main goal of empowerment education is to guide cancer patients to actively participate in self-decision-making and self-management in the process of treatment and rehabilitation, to change the image of powerless passive person and become an active person in control of their own life.

EVALUATION OF THE APPLICATION OF EMPOWERMENT EDUCATION FOR CANCER PATIENTS

The indexes selected for the application evaluation of empowerment education are also different according to different research purposes. Researchers will comprehensively evaluate the application effect of empowerment education by combining subjective and objective indicators. For the evaluation of subjective indicators, namely social psychological indicators, the Self-Management Efficacy Scale of cancer patients, Self-Rating Anxiety Scale, and Self-Rating Depression Scale were most frequently selected. Objective indicators, such as the incidence of adverse reactions in patients with chemoradiotherapy and the degree of cancer pain in patients, can be used to indirectly evaluate the impact of empowerment education on the utilization of health knowledge and the degree of behavioral change in patients.

Effective and comprehensive empowerment assessment of patients can help nurses to form an objective and accurate understanding of the effect of empowerment education.However, no localized authorization assessment tool has been developed in China.[28]There are some relevant scales in foreign countries, such as the Cancer Empowerment Questionnaire, which is the first questionnaire to verify the empowerment level of cancer patients.[29]It was developed by Dutch scholar van den Bergetal.[30]based on Zimmerman’s psychological empowerment theory. There are 40 items in the questionnaire, with 4 dimensions (personal strength,social support, community, and health care). Likert 5 rating is adopted, from 1 (strongly disagree) to 5 (strongly agree).The higher the total score, the stronger the feeling of empowerment of patients. The Patient Empowerment Scale is developed by Dr. Caroline Bulsara in Australia and is used to quantify empowerment levels in cancer patients. There are 15 items in total, and each item is rated by Likert 4,from complete agreement to complete disagreement, with 4–1 points, respectively. The higher the score, the higher the level of patient empowerment.[31]The Empowerment Scale for Women with Breast Cancer is compiled by Shin and Park,[32]Korean scholars. Thirty items are given in 3 dimensions (personal internal factors, interaction factors, and behavioral factors). Likert level 5 is adopted; the higher the score is, the better the empowerment level is. It is suggested that the scale developed in foreign countries should be localized or independently researched and developed for tumor patients under the background of Chinese cultural environment.

CONCLUSIONS

To sum up, the purpose of empowerment education is to stimulate the subjective initiative of patients’ disease management, to actively seek help for their own health problems, and according to the information, resources, and skills provided by the nurses, the target and plan of behavior change should be established for self-care. The impact of empowerment on patients is beneficial and long lasting.However, empowerment education in China is widely used in chronic diseases such as diabetes and stroke, and its application in cancer patients is still at the initial stage, with a relatively simple form and no reliable assessment tool, which is the direction for further in-depth research in the future.

Financial support and sponsorship

Nil.

Con flicts of interest

There are no conflicts of interest.