Social policy and empowerment

Mental Health Nursing,  Mar 2005  

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Discourses on empowerment appear to fall into three main categories. These are empowerment within the organisational environment, empowerment within resource management and empowerment of the self (Ryles, 1999). Mental health nurses as professionals working within the organisation of the NHS are expected to work across all three discourses of empowerment in order to implement the plethora of social policy documents recently published. In this article Marjorie Lloyd discusses the implications of this approach to practising empowerment for mental health nurses

Marjorie Lloyd, Lecturer in mental health nursing at North East Wales Institute of Higher Education, Wrexham

Social policy has, for at least the last decade, been espousing empowerment as a major part of service delivery within mental health services. (Department of Health, 1990; Department of Health, 1997) This is often cited as being due to the historical evidence of mental health patients being treated as powerless - both physically and mentally. However, one might argue that there is another, perhaps more sinister reason, that mental health nurses are encouraged to be empowering. Servian (1996) suggests that empowerment is a timely development within the need to reducing spiralling costs and rationing services. Mental health nurses have, therefore, found themselves in a position of, on the one hand trying to help people who suffer from mental illness to access services and, on the other limiting access to restricted services (Kirk and Glendinning, 1998).

For example, one way of rationing resources using the three empowerment categories identified earlier is the concept of health promotion. Using this intervention it is often assumed that providing information on how to manage a condition enables the service user to manage that condition themselves, thus empowering the person. Powers (2003) identifies that there is a strong suggestion within latest policy that if knowledge is power then people could be given more power over their health. This has been acknowledged by the government in their document entitled The Expert Patient (Department of Health, 2002a). Consequently through shifting the balance of power (Department of Health 2002b) the organisation empowers the workforce to share their knowledge and skills with their patients in order to empower them. Powers (2003) suggests that empowerment has become an intervention in itself which the patient may not have an option to refuse. Staff may then use rationing terms to marginalise those people who are not accepting or believing of their knowledge. Words that may be heard to describe this type of service user may sound too familiar as 'not engaging' or 'non compliant' (Barker, 2001). Such individuals may then be justifiably discharged from the service or worse, monitored by staff in the community as a purely risk management exercise.

Some mental health nurses therefore are now finding themselves in an uncomfortable position. When empowerment has gone wrong, the public, via the media, have been quick to blame those in power and those who have been empowered to manage or ration care. In 1998, and in response to public outcry, Frank Dobson the then health secretary stated that community care had failed (Department of Health, 1998) and in the same document stated that all mental health care should be 'safe, sound and supportive'. This means that only approaches to care that can be proven to work or are 'sound' should be used.

This leaves a gap for the subjective knowledge of the nurse and the person they are caring for. Lyotard (1979) calls this type of knowledge 'narrative knowledge'. It is that person's own story that does not and cannot be justified by science as it is different for everyone and cannot be generalised across a broad patient group. On the other hand, only scientific knowledge is acceptable within the organisation because the organisation relies upon science to maintain its power through knowledge (Foucault, 1967). The mental health nurse is now in an almost impossible role of 'binding agent' (Barker, 1999) attempting to blend the patient's narrative and society's expectations together to arrive at a narrative that is acceptable to each. However, because of the influence of the organisation over what type of knowledge is acceptable or 'sound', there is increasing evidence that mental health nurses will only be able to hear what fits within the scientific knowledge base of their profession (Powers, 2003). As the policy documents call for evidence-based practice, this by definition excludes individual experience as the evidence that is required and/or valued is scientific or empirical, that which can be observed and objectified (Barker, 2001).

Empowerment in practice therefore is, and can only be, recognised when the person receiving help uses language that is familiar to the nurse and his/her profession. Mental health nurses are therefore attempting to manage the 'myth of empowerment' (Patterson, 2001), because the only power that is acceptable to the organisation is the objective scientific knowledge that has been developed through empirical research.