The Ladder of Participation: Autonomy in Healthcare

I recently had an article published in Nursing Standard entitled ‘The Highest Possible Rung,’ which discusses the patients struggle for autonomy within health care.  This blog highlights some of the main issues discussed within the article.

The Ladder of Participation, developed by Arnstein (1969), has traditionally been used to help health professionals identify and understanding the power imbalance between themselves and their patients. It provides an opportunity for patient autonomy to be provided.

The Ladder represents eight stages of power, with steps further up the ladder representing greater patient participation and autonomy.  The Ladder highlights the vast differences in power, ranging from non-participation, tokenistic autonomy, and full patient power. This latter level of participation is the pinnacle of autonomy.

The eight levels of the Ladder, from the bottom rung and progressing upwards, are as follows:

  • Manipulation – a position of non-participation, where the health professional aims is to cure or educate the patient.

  • Therapy – another non-participative level, where the aim is to educate patients towards changing themselves rather than giving them a say in healthcare procedures.

  • Informing – the first step towards active participation, whereby the health professional informs the patient of their rights and options within the care process.

  • Consultation – participation becomes more active, comprising surveys, meetings and enquiries with the patient.

  • Placation – the health professional involves the patient in actively planning their care, but the ultimate decisions regarding the patient are still made by the nurse.

  • Partnership – by this stage power is redistributed via negotiation with patients, family and other health professionals. Planning and decision-making are shared.

  • Delegated power – the patient holds the predominant power regarding their own care.

  • Citizen control – the patient has total control and power regarding their own care.

As illustrated by the Ladder, there are contrasting levels of autonomy within Arnstein’s Model.  There are also differences in the participation needs and capabilities between patients.  Therefore, making decisions on which level of the Ladder of Participation is most suitable for a specific patient can be a challenge that requires an adaptive approach.

Factors to consider when assessing patient autonomy include:

  • The physical and mental capacity of the patient

  • Patient preference

  • Individual patient needs

  • Whether the patient wants family or close friends involved

  • Whether the patient can effectively convey their needs and preferences

  • Whether the patient is fully informed

Where the top rung of the ladder is not feasible, it is important for health professionals not to assume responsibility for the patient, but to provide facilitation (i.e. “enabling a person to do what otherwise he or she would not be able to do, by providing those parts of the action that are missing” ( Kitwood, 1997; p. 91).


Arnstein SR (1969) A Ladder of Citizen Participation. Journal of the American Planning Association. 35, 4, 216–224.

Nursing and Midwifery Council (NMC) (2008) Code of Conduct. London.

Kitwood T (1997) Dementia Reconsidered: The Person Comes First. Open University Press. 20, 7-8, 91.

Categories: Nursing, Personal/Professional Development

Tags: , , , , , ,

2 replies

  1. Interesting post Nicola, and well done on the article in Nursing standard.

  2. Thank you, Susan. I enjoy sharing what I learn with others.

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