Empowerment in healthcare: A thematic synthesis and critical discussion of concept analyses of empowerment.

OBJECTIVE: The objective of this study is to shed light on common characteristics revealed in concept analyses of empowerment to contribute to further understanding. A further objective is to discuss how the perspective of healthcare service users appeared in the concept analyses. 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 12 concept analyses included. The analysis process involved thematic synthesis as described by Thomas and Harden. RESULTS: The synthesis led to 13 descriptive themes structured according to antecedents, attributes and consequences of empowerment. The synthesis revealed how sparsely the question of equality and power in the relation between health professionals and healthcare service users is addressed. 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.

Safe Surgery Checklist, Patient Safety, Teamwork, and Responsibility-Coequal Demands? A Focus Group Study.

The use of World Health Organization's (WHO's) Safe Surgery checklist is an established practice worldwide and contributes toward ensuring patient safety and collaborative teamwork. The aim of this study was to elucidate operating room nurses' and operating room nursing students' experiences and opinions about execution of and compliance with checklists. We chose a qualitative design with semistructured focus group discussions. Qualitative content analysis was conducted. Two main themes were identified; the Safe Surgery checklists have varied influence on teamwork and patient safety, and taking responsibility for executing the checks on the Safe Surgery checklist entails practical and ethical challenges. The experiences and opinions of operating room nurses and their students revealed differences of practices and attitudes toward checklist compliance and the intentions of checklist procedures. These differences are related to cultural and professional distances between team members and their understanding of the Safe Surgery checklists as a tool for patient safety.

User participation in a Municipal Acute Ward in Norway: dilemmas in the interface between policy ideals and work conditions.

User participation has become an increasingly important principle in health care over the last few decades. Healthcare professionals are expected to involve patients in treatment decisions. Clear guidance as to what this should entail for professionals in clinical work is not accounted for in legislation. In this study, we explore how healthcare professionals in a Municipal Acute Ward perceived, experienced and performed user participation. The ward represents a new short-time service model for emergency assistance in Norway. We focused on the challenges the professionals faced in clinical work and how they dealt with these. Data were drawn from qualitative interviews with 11 healthcare professionals and from 10 observations in relation to previsits and physician's rounds in the ward. Transcripts of interviews and observations were analysed using a method for systematic text condensation. In the analysis, we applied Lipsky's perspective on dilemmas of street-level bureaucrats. The results show that that the professionals perceived user participation as an important and natural part of their work. They experienced difficulties related to collaboration with patients, caregivers, and professionals in other services, and with framework conditions that caused conflicting expectations, responsibility, and priorities. The professionals seemed to take a pragmatic approach to user participation, managing it within narrow perspectives. Our study indicates that the participants dealt with the dilemmas at the cost of user participation. The results demonstrate that there is a gap between the outlined health policy and the professionals' opportunities to fulfil this policy in clinical work regarding user participation. The policy decision-makers should recognise the balancing work required of healthcare professionals to deal with difficulties in clinical work. The knowledge that professionals possess as performers of services and the need for valuing in policy processes should be acknowledged.

Validation of the Norwegian version of MAPPIN'SDM, an observation-based instrument to measure shared decision-making in clinical encounters.

OBJECTIVE: To validate the Norwegian version of MAPPIN'SDM observer scales with regard to reliability, accuracy and the extent to which the scales include the essentials of the shared decision-making concept. METHODS: Three MAPPIN'SDM scales, focusing on the skills of doctor, patient and dyad, were applied to audiovisual records of 35 decision sequences. Inter-rater reliabilities were determined based on kappa coefficients. Sensitivities and specificities were calculated with regard to an expert reference standard. Convergent validities were calculated with the OPTION5 scale. MAPPIN'SDM was qualitatively compared to OPTION5 using Makoul & Clayman's Integrative Model structure. RESULTS: Inter-rater reliabilities were high on average over 11 items in each of three observer scales (MAPPINdoctor=0.77, MAPPINpatient=0.82, MAPPINdyad=0.77). Patient involvement was detected accurately (MAPPINdyad: mean sensitivity/specificity 93/91%). Comparison with OPTION5 showed weak to moderate correlation (Spearman's ρ/p-value: MAPPINdoctor:=0.44/0.009, MAPPINpatient: 0.38/0.024, MAPPINdyad 0.40/0.016) and little content overlap. CONCLUSION: MAPPIN'SDMnorge is capable of assessing SDM highly reliably and accurately. Divergence from OPTION5 reflects explicit disagreement regarding the concept's assumptions. PRACTICE IMPLICATIONS: MAPPIN'SDMnorge is ready for use in Norway. In-depth debate on the SDM concept's essentials is urgently needed.

Maternity groups in the postpartum period at well child clinics - mothers' experiences.

AIMS AND OBJECTIVES: To explore mothers' experiences as participants in maternity groups at well child clinics (WCCs). BACKGROUND: The level of psychological distress that new mothers have may be related to the quantity of social support they receive. Maternity groups to support new parents have a long tradition at WCCs in Norway, and most of the clinics have offered these groups. However, there is little knowledge about mothers' experiences of participating in these groups. DESIGN: Qualitative design. METHOD: Focus group interviews with mothers who had participated in maternity groups facilitated by public health nurses (PHNs) at WCCs. Interpretive description was used to analyse the transcripts from the interviews. RESULTS: Eight focus group interviews were conducted with a total of 30 mothers who had participated in maternity groups at WCCs in two counties in eastern Norway. The analysis resulted in one main category, 'The maternity group's salutogenic importance' and three subcategories, 'Networks that can last for many years', 'Fellowship with others in the same situation' and 'Become confident in mothering'. CONCLUSION: Mothers wanted fellowship and found it important to share experiences with other mothers. Maternity groups offered to parents are essential to meet parents' need to discuss experiences and challenges related to parenting. Maternity groups can also create a basis for establishing a social network for those who want it. RELEVANCE TO CLINICAL PRACTICE: Well child clinics should offer all mothers the opportunity to participate in groups to strengthen their social relations and their confidence in parenting. PHNs play an important role in facilitating groups for first-time parents. Group leadership can influence how mothers in a group connect and whether the parental role is affected.

Treating symptoms or assisting human development: Can different environmental conditions affect personal development for patients with severe mental illness? A qualitative study.

BACKGROUND: Recent research suggests that a basic anomaly in self-experience may be a core factor in patients with severe mental illnesses. Given the importance of sense of self, the traditional treatment of symptoms might not be the most effective for these groups of patients. This qualitative study examines how differences in social environmental conditions, organized as education or treatment, might affect personal development in patients with severe mental illness. METHODS: A qualitative hermeneutical design was used. Data were collected through qualitative interviews. Informants included 14 patients in psychiatric treatment and 15 students at schools for adults with mental illness. Most informants were interviewed on two occasions, 6-8 months apart, totaling 47 interviews. All participants had been diagnosed with severe mental illness with pronounced impact on daily functioning (most often psychoses or personality disorders) for a minimum of 2 years. RESULTS: Findings and interpretations showed that the students experienced a supportive environment focused mostly on education. They described personal and enduring development in areas such as capacity for relationships, regulation of symptoms, subjective well-being, and integration in society. The patients experienced an environment focused more on treatment of their illness and less on personal development and interests. They described little development, much loneliness, a poor quality of life, an objectifying attitude of themselves and others, and hopelessness. CONCLUSIONS: Even if more research is needed, findings indicate that for this group of patients, problems may be closely related to identity development. Therefore, instead of solemnly focusing on specific symptoms, it might be more effective to support patients' personal and social development by offering intensive and lasting social environmental conditions. This includes stable and mutual relationships, intrinsically motivated activities, and an environment that supports personal choices, acceptance, and development.

Parental groups during the child's first year: an interview study of parents' experiences.

AIMS AND OBJECTIVES: To highlight what was important to parents with respect to consultation groups at well-child clinics. BACKGROUND: Parents managing of their role as parents affect the child's health and are therefore an important priority for public health. Well-child clinics in Norway practise consultations in groups to support parents and to facilitate social network; however, few studies explore parents' perspective of this kind of groups. DESIGN: Grounded theory. METHODS: We used classical grounded theory with a generative and constant comparative approach. Data were collected through seven focus groups and two individual interviews with the parents of children aged 8-15 months. RESULTS: The parents were most concerned about how to achieve connection without accountability and how to obtain relevant health information. They managed this by 'multipositioning', encompassing the strategies of: (1) practising conditional openness, (2) seeking to belong, (3) awaiting initiative and (4) expecting balanced health information. The use of these strategies explains how they resolved their challenges. CONCLUSION: Parental groups seem to be popular and have great potential to establish a social network; however, underestimating the need for structure and continuity in the groups might cause this opportunity to be missed. RELEVANCE TO CLINICAL PRACTICE: Understanding parents' perspectives will be useful when planning strategies to strengthen parental groups at well-child clinics and that the engaged organisers will account for this need to ensure public health work of high quality and effectiveness for parents.

Empowering dialogues--the patients' perspective.

The aim of the study was to highlight the patients' experiences and perspectives of the dialogue with the health professionals at a pain clinic. This knowledge can develop and give nuanced understanding of patient empowerment and sense of control. Qualitative content analysis was used to reveal the meaning of the patients' experiences and perspectives during focus group interviews. The findings and interpretations revealed the main theme; preconditions and opportunities for participation. The main theme was represented by four subthemes; means for common understanding, basis for collaboration, acknowledgement and legitimacy. The findings and interpretations are discussed in the light of an evolving theory on women's sense of control while experiencing chronic pain and empowerment. The dialogue is very important related to aspects of control, remoralization and demoralization and is affected by external structural factors. This underlines the importance of further research focusing on empowerment and power.

'Easier said than done': empowering dialogues with patients at the pain clinic - the health professionals' perspective.

AIM: The aim of the present study was to develop knowledge of the dialogue between the health professionals and the patient in the empowerment process. BACKGROUND: Dialogue is important regarding empowerment. METHODS: Transcript-based qualitative content analysis was used to reveal the meaning of five health professionals' views and reflections as reported during three focus group interviews. RESULTS: The dialogues are important and have varying purposes and characteristics. Conducting good dialogues represents challenges. CONCLUSION: Engaging in dialogues according to the principles of empowerment was easier said than done. IMPLICATIONS FOR NURSING MANAGEMENT: Establishing supervision groups, considering the dialogue as part of the therapy and organizing the service in a way that makes dialogues and real participation possible. Further research may focus on the patients' views and reflections regarding the dialogues with the health professionals. What is new knowledge about the complexity and the challenges in conducting dialogues in the empowerment process?

Communication--a core concept in client supervision by public health nurses.

AIM: The aim of this study was to explore public health nurses' reflections on client supervision. BACKGROUND: Reflection on actions represents a possible basis for constructing and refining assumptions on current theories used in practice thus making knowledge development possible. METHODS: Transcript-based qualitative content analysis was used to analyse the findings from individual interviews with 13 female public health nurses. FINDINGS: Communication is a core concept of client supervision by public health nurses and includes the following themes: (1) building a trusting relationship, (2) looking beyond the current situation, (3) creating a partnership and equality and (4) considering the challenge involved in trying to act in the clients' best interests. CONCLUSIONS: This study shows that public health nurses' reflection and reflecting related to their provision of client supervision revealed one possible assumption regarding their theories-in-use; communication is a core concept in client supervision. Communication is viewed from a hermeneutic perspective--as the meaning of the interaction between the public health nurses and the client in the supervision is reflected upon and interpreted.

Conducting client supervision in community health care.

The aim of the present study was to examine registered public health nurses' views and reported actions related to client supervision in community health care. Transcript-based, qualitative and interpretative content analysis was used to analyse the findings from six focus group interviews. The main findings represented the following themes: the components of the assessment basis related to choosing supervision as an intervention strategy, the strategies related to conducting supervision and the meaning of supervision as an intentional act. In conclusion, the registered public health nurses' reported model for conducting supervision seems to correspond with principles in the new strategies for health promotion initiated by the World Health Organization. Further research is needed to explore what the nurses really do when conducting supervision in order to provide extended knowledge about their model.

Evaluation of the concept of supervision related to public health nurses in Norway.

AIM: The aim of the study is to clarify the concept of supervision by means of concept analysis, in order to evaluate the concept's application to the practise of public health nurses. BACKGROUND: According to the World Health Organization, a change in strategies for improving public health is necessary. This change demands new strategies. There exists little research concerning intervention strategies in public health. The concept of supervision is well used, but neither well-defined nor well described, either within the nursing discipline or across disciplinary boundaries. METHODS: The method is a review of literature. Twenty scientific papers covering the years 1996-2001 are analysed, using a concept-analysis methodology. FINDINGS: Supervision can be defined as a formal, pedagogical, relational enabling process, related to professional competence. Relationship and dialogue are central aspects. Supervision is based on theory and humanistic values, has a normative, formative and restorative function. The supervisor's competence is of great importance. Supervision has unclear boundaries with concepts such as psychotherapy, consultation and counselling. CONCLUSION: The concept of supervision as described in the selected papers is applicable to public health nurses' supervision of clients, with adaptation caused by the contextual variation of the relationship. Related to clients, supervision can be defined as a formal, pedagogical, relational enabling process with the purpose to strengthen resources, enhance assertiveness and improve independence and coping. It is necessary that registered public health nurses have the competence to supervise.

Client supervision: meaning and experiences from the perspective of Norwegian public health nurses.

The aim of the present study was to examine the meaning and experiences of client supervision from the perspective of Norwegian public health nurses. The World Health Organization (WHO) states that new intervention strategies to improve public health are necessary. Supervision represents such a strategy. Three focus groups were interviewed twice. The data were analyzed by qualitative content analysis. The findings revealed three themes: (i) the meaning of the umbrella term client supervision; informing, teaching, giving advice and ensuring the quality of supervision; (ii) factors influencing supervision; the public health nurses' available time and competence and the clients' ability to be supervised; and (iii) events and content representing the complexity of conducting supervision. In conclusion, the width of the concept, the influencing factors and the complexity claim that public health nurses have competence to supervise.