Is this really Empowerment? Enhancing our understanding of empowerment in patient and public involvement within clinical research.

BACKGROUND: There has been a growing push to involve patients in clinical research, shifting from conducting research on, about, or for them to conducting it with them. Two arguments advocate for this approach, known as Patient and Public Involvement (PPI): to improve research quality, appropriateness, relevance, and credibility by including patients' diverse perspectives, and to use PPI to empower patients and democratize research for more equity in research and healthcare. However, while empowerment is a core objective, it is often not clear what is meant by empowerment in the context of PPI in clinical research. This vacancy can lead to insecurities for both patients and researchers and a disconnect between the rhetoric of empowerment in PPI and the reality of its practice in clinical trials. Thus, clarifying the understanding of empowerment within PPI in clinical research is essential to ensure that involvement does not become tokenistic and depletes patients' capacity to advocate for their rights and needs. METHODS: We explored the historical roots of empowerment, primarily emerging from mid-20th century social movements like feminism and civil rights and reflected the conceptual roots of empowerment from diverse fields to better understand the (potential) role of empowerment in PPI in clinical research including its possibilities and limitations. RESULTS: Common themes of empowerment in PPI and other fields are participation, challenging power structures, valuing diverse perspectives, and promoting collaboration. On the other hand, themes such as contextual differences in the empowerment objectives, the relationship between empowerment and scientific demands, research expertise, and power asymmetries mark a clear distinction from empowerment in other fields. CONCLUSION: PPI offers potential for patient empowerment in clinical trials, even when its primary goal may be research quality. Elements like participation, sharing opinions, and active engagement can contribute to patient empowerment. Nonetheless, some expectations tied to empowerment might not be met within the constraints of clinical research. To empower patients, stakeholders must be explicit about what empowerment means in their research, engage in transparent communication about its realistic scope, and continuously reflect on how empowerment can be fostered and sustained within the research process.

What Do We Know About Sharing Power in Co-Production in Mental Health Research? A Systematic Review and Thematic Synthesis.

BACKGROUND: Guidance on co-production between researchers and people with lived experience was published in 2018 by the National Institute for Health and Care Research (NIHR) advisory group, previously known as INVOLVE. This guidance described sharing power as a key principle within co-production. Authentic sharing of power within co-produced mental health research does not always occur however and remains a challenge to achieve within many projects. OBJECTIVES: To explore what has been learned about the sharing of power in co-production within mental health research since the publication of these guidelines, by synthesising qualitative literature relating to power within co-produced mental health research. METHODS: We carried out a systematic review with thematic synthesis. We searched CINHAL, Embase and PubMed databases to identify qualitative or mixed-method studies relating to power within co-produced mental health research. Studies were independently screened by two reviewers for inclusion and appraised using the Critical Appraisal Skills Programme tool (CASP) for qualitative research. RESULTS: We identified nine papers that met the criteria for inclusion and were included in the synthesis. Three themes were generated: (1) Battling to share power against a more powerful system, (2) Empowerment through relationships and (3) The journey is turbulent, but it is not supposed to be smooth. CONCLUSIONS: Results highlight that power is pervasive, especially within the hierarchical systems research is often conducted within. Sharing power within co-produced mental health research is an ongoing complex process that is not intended to be easy. Respectful trusting relationships can help facilitate power sharing. However, ultimately meaningful change needs to come from research funders, universities and NHS providers. PATIENT OR PUBLIC CONTRIBUTION: The study authors include a lived experience researcher who contributed to the review design, analysis and write-up.

Relationship power attenuated the effects of gratitude on perceived partner responsiveness and satisfaction in romantic relationships.

There is a gap in whether relationship power affects the association between gratitude and relationship satisfaction in romantic relationships. Based on the relationship maintenance model and the social distance theory of power, the present study adopted a digital questionnaire design on an online platform to test the mediating role of perceived partner responsiveness between gratitude and satisfaction as well as the moderating role of relationship power. A total of 825 subjects (Mage = 27.2, SD = 10.6; female 46.9%) who had been in romantic relationships for more than six months participated in this study. Overall, the results of the moderator-mediator model indicated that, compared to individuals with low levels of relationship power, the relationship between gratitude and perceived partner responsiveness as well as that between perceived partner responsiveness and relationship satisfaction was weaker among those with high levels of power. These findings are revealing for interventions designed to promote satisfaction between couples with power imbalances.

Determinants of women's empowerment in Nepal.

INTRODUCTION: Nepal is characterized by low empowerment of women which may have negative effects on their health status as well as sexual and reproductive rights. We seek to identify key determinants of women empowerment in Nepal using a rich set of socio-demographic and socio-economic characteristics as well as behavioral factors and regional indicators. METHODS: This study utilizes 4,211 women aged between 15 and 49 years from the 2022 Demographic and Health Survey (DHS) for Nepal. Following the previous study for Mozambique, we use Principal Component Analysis (PCA) to identify components of women's empowerment along three domains: beliefs about violence, decision-making and control over sexuality and safe sex. We use logistic regressions to identify significant predictors of empowerment in each domain and provide crude and adjusted odds ratios along with their 95% confidence intervals. RESULTS: We found that older age is generally associated with higher empowerment across all these domains. Interestingly, while partner controlling behavior tended to decrease empowerment in beliefs about violence and control over sexuality, it was linked to increased decision-making empowerment. Notable regional differences emerged, with higher levels of empowerment observed in the Madhesh and Sudurpashchim regions. Further, education level and wealth were correlated with increased empowerment in control over sexuality and safe sex, though not in the other two domains. Access to media showed mixed effects, reducing empowerment in decision-making but enhancing it in control over sexuality and safe sex. CONCLUSION: Our results have many similarities but also notable differences with previous literature which emphasizes the importance of regular and region-specific studies of women's empowerment, acknowledging the potential for its change over time and also the prevailing differences across regions.

Power and positionality in the practice of health system responsiveness at sub-national level: insights from the Kenyan coast.

BACKGROUND: Health system responsiveness to public priorities and needs is a broad, multi-faceted and complex health system goal thought to be important in promoting inclusivity and reducing system inequity in participation. Power dynamics underlie the complexity of responsiveness but are rarely considered. This paper presents an analysis of various manifestations of power within the responsiveness practices of Health Facility Committees (HFCs) and Sub-county Health Management Teams (SCHMTs) operating at the subnational level in Kenya. Kenyan policy documents identify responsiveness as an important policy goal. METHODS: Our analysis draws on qualitative data (35 interviews with health managers and local politicians, four focus group discussions with HFC members, observations of SCHMT meetings, and document review) from a study conducted at the Kenyan Coast. We applied a combination of two power frameworks to interpret our findings: Gaventa's power cube and Long's actor interface analysis. RESULTS: We observed a weakly responsive health system in which system-wide and equity in responsiveness were frequently undermined by varied forms and practices of power. The public were commonly dominated in their interactions with other health system actors: invisible and hidden power interacted to limit their sharing of feedback; while the visible power of organisational hierarchy constrained HFCs' and SCHMTs' capacity both to support public feedback mechanisms and to respond to concerns raised. These power practices were underpinned by positional power relationships, personal characteristics, and world views. Nonetheless, HFCs, SCHMTs and the public creatively exercised some power to influence responsiveness, for example through collaborations with political actors. However, most resulting responses were unsustainable, and sometimes undermined equity as politicians sought unfair advantage for their constituents. CONCLUSION: Our findings illuminate the structures and mechanisms that contribute to weak health system responsiveness even in contexts where it is prioritised in policy documents. Supporting inclusion and participation of the public in feedback mechanisms can strengthen receipt of public feedback; however, measures to enhance public agency to participate are also needed. In addition, an organisational environment and culture that empowers health managers to respond to public inputs is required.

Parent Experiences of Empowerment: Understanding the Role of Parent Empowerment in Child Health Promotion.

BACKGROUND: Establishing healthy behaviors during a child's first 5 years is essential for healthy growth. Parents are targeted as agents of change because they serve as primary models of behavior during this period. Although parent-focused interventions often target empowerment as a driver of change, our understanding of how parents experience the process of empowerment in the context of child health promotion remains limited. OBJECTIVE: This qualitative study explored the process by which parents gain empowerment through participation in a health promotion intervention. METHODS: Semi-structured interviews were conducted with 37 low-income parents who participated in Parents Connect for Healthy Living (PConnect), a 10-week empowerment-centered obesity prevention intervention. Data were analyzed using inductive-deductive thematic analysis and guided by empowerment theories. RESULTS: Most parents were Hispanic/Latino (41%) and female (97%). Five themes emerged that correspond to the process by which parents gained empowerment: (1) friendships formed and relationships strengthened during PConnect, (2) parents strengthened relationships with their children and believed in their ability to parent successfully, (3) the experience of knowledge led to behavior change, (4) parents used new resources to improve family health, and (5) parents took action. CONCLUSION: Empowerment theory should be a component of health promotion programs.

Empowerment of Lay Mental Health Workers and Junior Psychologists Online in a Task-Shared, Rural Setting in Kerala, India.

BACKGROUND: Patients with severe mental health issues who live in isolated rural areas are difficult to reach and treat. Providing effective treatment is difficult because mental health problems are complex and require specialized knowledge from a range of professionals. Task-sharing with lay mental health workers (LMHWs) has potential but requires proper training and supervision to be effective. This article reports on the challenges and facilitators experienced in empowering LMHWs in their role, with the help of a technology supported supervision group. The study sought to understand the functioning of the Empowering Supervisory Group (ESG) in the context of junior psychologists and LMHWs in rural India, and investigate how they experienced it by exploring challenges, lessons and empowerment. METHODS: Qualitative analysis of interviews with the 22 ESG participants and their supervisors. RESULTS: A total of three discrete phases of supervision were identified where supervisors responded to the changing needs of the group. This began with building trust at a baseline level, tackling issues with competence and autonomy and finally experiencing meaning and impact through self-determination. The experience of empowerment even in an online setting was very beneficial given the challenges of working in rural areas. CONCLUSION: Empowerment based supervision of LMHWs and junior psychologists online enables a level of engagement that positions them to engage in community mental health practices with greater independence and confidence.

Empowering the younger generation increases their willingness for intergenerational reconciliation in the context of climate change.

Climate change can evoke intergenerational conflict. Structural inequalities and their unequal impact on generations can increase perceptions of collective victimhood among the younger generation (< 30 years) and bear the risk of social tensions between the young and the elderly. An experimental study (N = 434) showed that younger people perceived an increased risk of future victimhood. In line with a needs-based approach, the young reported an increased desire to pursue agentic intergroup goals, indicating a heightened need for agency. However, when the young received empowering messages that affirmed their ingroup agency, their willingness to reconcile with the old generation increased, whereas informing them about non-agentic ingroup behavior did not affect reconciliation (between-subjects manipulation). While empowering messages from the outgroup ("Grannies for Future") that directly affirmed the young generations' agency for climate change mitigation as well as empowering messages from the ingroup that indirectly affirmed ingroup agency in domains unrelated to climate change both addressed the need for agency, only outgroup empowerment promoted intergenerational reconciliation. However, empowerment did not affect support for collective climate action. We discuss empowerment as an avenue for resolving intergroup conflict in the context of climate change and possible consequences for climate action and social change.

Navigating Accountable Conversations in Health Care: Balancing Power Dynamics.

Effective communication is crucial in health care and contributes to safe patient care and organizational excellence. Hierarchical differences can negatively affect communication among clinicians; however, recognizing and addressing power imbalances can improve patient safety. Individuals can feel empowered to express concerns and provide constructive feedback through clear communication with active listening. Perioperative nurses and leaders can use a variety of strategies to enhance accountable (or critical) conversations, such as structured communication models that guide participants through conversations and standardized procedures and tools to enhance the quality of team communication. This article provides an overview of accountable conversations, discusses the importance of structured communication models, and offers scenario-based examples using two structured models to enhance the reader's understanding. Finally, the article describes cultural competence and the leader's role in developing a culture of accountability.

Reliability and validity of the Chinese version of the coronary artery disease empowerment scale (CADES) in patients with coronary artery disease after percutaneous coronary intervention.

BACKGROUND: Empowerment is a comprehensive concept involving intrapersonal, interactional, and behavioral aspects. However, there is a lack of a specific empowerment scale for Coronary artery disease (CAD) related to knowledge and skills in China. The reliability and validity of the Coronary Artery Disease Empowerment Scale (CADES) need to be tested. This study aimed to assess the reliability and validity of the Chinese version of CADES among patients with CAD in China. METHODS: The study adopted a cross-sectional design. After obtaining the copyright by contacting the author, the original English CADES was developed into Chinese by forward translation, back-translation, cross-cultural adaptation, and a pretest (30 patients). The Chinese version of CADES was administered to 391 CAD patients between September 2022 and June 2023, with the reliability and validity of the version evaluated. Exploratory factor analysis and confirmatory factor analysis were performed to examine the underlying factor structure of the translated questionnaire. The Cronbach's α coefficient, Guttman's split-half coefficient, and McDonald's omega coefficient were calculated to verify the scale's reliability. RESULTS: For the Chinese version of CADES, the scale-content validity index was 0.972, with the item-content validity index ranging from 0.86 to 1.00. The questionnaire comprised 25 items, and exploratory factor analysis extracted four factors with loadings > 0.40, explaining 62.382% of the total variance. An acceptable model fit was achieved (χ2/df = 1.764, RMSEA = 0.060, TLI = 0.901, CFI = 0.912, IFI = 0.913). The Cronbach's α coefficient of the total questionnaire was 0.928, with coefficients for the four factors ranging from 0.683 to 0.913. The split-half reliability coefficient was 0.777, and the McDonald's omega reliability coefficient was 0.926. CONCLUSIONS: The Chinese version of CADES is reliable and valid among CAD patients in China. This instrument can serve as a valuable reference for guiding the implementation of targeted intervention strategies tailored to the empowerment status of CAD patients in clinical practice.

Not All Powerful People Are Created Equal: An Examination of Gender and Pathways to Social Hierarchy Through the Lens of Social Cognition.

Across four studies (N = 816 U.S. adults), we uncovered a gender stereotype about dual pathways to social hierarchy: Men were associated with power, and women were associated with status. We detected this pattern both explicitly and implicitly in perceptions of individuals drawn from Forbes magazine's powerful people lists in undergraduate and online samples. We examined social-cognitive implications, including prominent people's degree of recognition by individuals and society, and the formation of men's and women's self-concepts. We found that power (status) ratings predicted greater recognition of men (women) and lesser recognition of women (men). In terms of the self-concept, we found that women internalized the stereotype associating women with status more than power implicitly and explicitly. Although men explicitly reported having less status and more power than women, men implicitly associated the self with status as much as power. No gender differences emerged in the desires for power and status.

Individual power in human motivation - Review and theoretical perspective.

There are many studies in Psychology and other sciences about the concept of power. We believe that individual power is one of the most critical factors in human motivation, which is considered by prominent motivation theories, like Choice Theory or McClelland's Human Motivation Theory. This paper aims to study the concept of power, considering ego and social orientation. The extensive literature review allowed us to describe the concepts related to those orientations and to induce a theoretical model that may typify and explain the relationships between the two perspectives of power. The model might contribute to describing four motivational profiles, namely the imperator, with high ego-power and power over others orientation; the supporter, with low ego-power and power with other orientation; the leader, with high ego-power and power with others orientation; and the controller, with low ego-power and power over others orientation. The Ego-Social Power Motivation Model could help describe the power signature of an individual. This individual picture might help psychologists work on motivations, attitudes, and behaviours to enhance people's lives and well-being.

Empathic stress is decreased by prior stressor experience and increased in a position of power.

The observation of a stressed individual can trigger a stress response in a passive observer. Little is known about the mechanisms of this so-termed empathic stress, including the observer's empathic involvement with the stressful situation. In 108 opposite-sex stranger dyads, we expected to increase the observer's empathic involvement with a stressed target performing a standardized laboratory stressor (Trier Social Stress Test, TSST; Kirschbaum et al., 1993) by exposing observers themselves to the TSST one week earlier. Conversely, we intended to decrease empathic involvement by granting observers a powerful position over the targets (by asking them to evaluate the targets' TSST performance and allegedly decide on their financial compensation). A control group without any manipulation was also included. In the preregistered data analysis, two types of empathic stress were investigated: vicarious stress, which evolves irrespective of the target's stress response, and stress resonance, which is proportional to the target's stress response. Irrespective of manipulation, observers exhibited vicarious stress in subjective and high-frequency heart rate variability (HF-HRV), and synchronized with the targets' stress reactivity in cortisol release. Prior TSST experience unexpectedly decreased observers' self-reported empathy and vicarious cortisol stress reactivity. The power manipulation, conversely, led to stronger observer vicarious stress in overall heart rate and HF-HRV reactivity. Based on Wondra and Ellsworth's (2015) appraisal theory, we propose that, due to their prior stressor exposure, observers habituated to said stressor, and consequently changed their evaluation of the target's stressful situation. In contrast, observers in the powerful position may have felt responsible for the targets, triggering a stronger vicarious stressful experience.

Aiming for transformations in power: lessons from intersectoral CBPR with public housing tenants (Québec, Canada).

Intersectoral collaborations are recommended as effective strategies to reduce health inequalities. People most affected by health inequalities, as are people living in poverty, remain generally absent from such intersectoral collaborations. Community-based participatory research (CBPR) projects can be leveraged to better understand how to involve people with lived experience to support both individual and community empowerment. In this paper, we offer a critical reflection on a CBPR project conducted in public housing in Québec, Canada, that aimed to develop intersectoral collaboration between tenants and senior executives from four sectors (housing, health, city and community organizations). This single qualitative case study design consisted of fieldwork documents, observations and semi-structured interviews. Using the Emancipatory Power Framework (EPF) and the Limiting Power Framework (LPF), we describe examples of types of power and resistance shown by the tenants, the intersectoral partners and the research team. The discussion presents lessons learned through the study, including the importance for research teams to reflect on their own power, especially when aiming to reduce health inequalities. The paper concludes by describing the limitations of the analyses conducted through the EPF-LPF frameworks and suggestions to increase the transformative power of future studies.

The last word: An analysis of power dynamics in clinical notes documenting against-medical-advice discharges.

Against Medical Advice (AMA) discharges pose significant challenges to the healthcare system, straining patient-clinician relationships while contributing to avoidable morbidity and mortality. Furthermore, though these discharges culminate in patients' departure from hospitals, their effects reverberate long after, propagated by clinician notes stored in patients' medical records. These notes capture exceptionally fraught interactions between patients and providers, describing the circumstances surrounding breakdowns in clinical relationships. Additionally, they represent just one side of complex, contentious social interactions, for in describing AMA discharges, clinician notewriters quite literally have the last word. For these reasons, notes documenting AMA discharges provide insight into the ways in which clinicians conceptualize, characterize, and propagate power differentials in the contemporary healthcare system. Here, we present a qualitative thematic analysis of 185 notes documenting AMA discharges from a large urban US medical center, interpreting note dynamics through three sociological models of power analysis: (i) the distributive model of power promulgated by Max Weber, (ii) the collectivist power model characterized by Talcott Parsons and Hannah Arendt, and (iii) structural interpretations of power developed by Michel Foucault. We argue that in documenting AMA discharges, clinicians appear to conceive of their relationship with patients in almost exclusively distributive terms, which in turn contributes to an adversarial dynamic whereby both patients and clinicians ultimately suffer disempowerment. We furthermore argue that by facilitating clinicians' recognition of power's collectivist and structural dimensions, we may help transform breakdowns in patient-clinician relationships into opportunities for collaboration.

The effect of practice environments and psychological empowerment perceptions of nurses on their care behaviours: A cross-sectional study.

AIM: The aim of this study was to examine the effect of professional and individual characteristics, practice environments and psychological empowerment perceptions of nurses on their care behaviours. DESIGN: The study used a cross-sectional research design following the STROBE guidelines. METHODS: The sample of this descriptive and correlational study consisted of 584 nurses working in a university hospital in Turkey. The data were collected between January and June 2023 using the Nursing Information Form, the Practice Environment Scale of the Nursing Work Index (PES-NWI), the Psychological Empowerment Scale (PES), and the Caring Behaviours Scale-30, and analysed using descriptive statistics, Spearman's correlation and multiple linear regression. RESULTS: It was determined that PES-NWI, PES and Caring Behaviours Scale (CBI-30) scores of nurses were higher than the average. The study revealed that certain professional and individual characteristics of nurses, practice environments and psychological empowerment perceptions had an effect on their care behaviours. CONCLUSION: The results of the study showed that nurses' PES-NWI, PES and CBI-30 scores were higher than the average, and that certain professional and individual characteristics of nurses, practice environments and psychological empowerment perceptions had an effect on care behaviours. Nursing service managers, in particular, are required to understand the importance of this relationship and create appropriate working conditions which are integrated with psychological empowerment to improve caring behaviours of nurses.

How infants predict respect-based power.

Research has shown that infants represent legitimate leadership and predict continued obedience to authority, but which cues they use to do so remains unknown. Across eight pre-registered experiments varying the cue provided, we tested if Norwegian 21-month-olds (N=128) expected three protagonists to obey a character even in her absence. We assessed whether bowing for the character, receiving a tribute from or conferring a benefit to the protagonists, imposing a cost on them (forcefully taking a resource or hitting them), or relative physical size were used as cues to generate the expectation of continued obedience that marks legitimate leadership. Whereas bowing sufficed in generating such an expectation, we found positive Bayesian evidence that all the other cues did not. Norwegian infants unlikely have witnessed bowing in their everyday life. Hence, bowing/prostration as cue for continued obedience may form part of an early-developing capacity to represent leadership built by evolution.

Dark and light university: The relationship between dark and light personality traits and educational choices and the desire for power as a mediating factor.

The present research investigates the role of dark and light personality traits in determining academic discipline preferences among university students. Two studies showed that university students with relatively high scores on dark personality traits (specifically, narcissism and Machiavellianism) and relatively low scores on light personality traits are over-represented in business and law programs, compared to psychology and other academic disciplines. The results further suggest that personality is a distal determinant of academic discipline choice, with human values being the proximal determinant. Specifically, high scores in dark/low light personalities express a desire for power, which explains why they choose economics or law as their academic discipline. Contrary to our expectations, low dark/high light personalities were not over-represented in psychology, compared to other academic disciplines. Overall, our findings highlight the importance of considering personality traits and human values in understanding academic discipline choices among university students. Recognizing these factors can inform educational institutions in developing strategies to better support students in aligning their academic pursuits with their personal characteristics and values.