Loci of Control

FIRST, A DISCLAIMER: I realize after writing this post that it does not have many positive things to say about physicians. I know a lot of really great doctors – in my experience, the sh*tty ones are few and far between. But the exception sometimes proves the rule. The bad doctors not only show you how not to practice medicine, they also highlight how crucial nurses are. Often your nurse is also your advocate.

And now, back to our regularly scheduled programming…

Friday’s lecture was all about communication, defining “health,” cultural competence and meeting clients where they are. One concept we spent a lot of time discussing really hit close to home for me.

It’s known as “locus of control,” and it’s basically where an individual places the responsibility for something that happens in their life – externally or internally. If you have an external locus of control, for example, you might explain tardiness to class by the traffic conditions or the alarm clock not going off. Someone with a more internal orientation might instead think that they could have left 10 minutes earlier or double-checked the alarm the night before. People with internal loci of control typically believe that they do have some ability to effect change in their lives, whereas those with external loci usually view life as happening “to them”. That is a broad generalization but keep in mind that different situations will yield different orientations in the same person.

That is what our instructor tried to hammer home to us in class. Most people will have inconsistencies when it comes to understanding their health and what they can do it about it. So it is important to listen carefully, discern where our clients are, and respond accordingly. For example, a person with type II diabetes who has an external locus of control may feel helpless about making changes in exercise and nutrition habits to improve his/her health. With this orientation, simply handing this person a brochure on dietary changes will usually be unsuccessful. The first step in effective nursing is meeting your clients where they are, then guiding them toward where they need to be when it comes to changing behavior.

And just as a client can be too externally oriented and blame everything on factors beyond his/her control, it is also possible to be too internally oriented and start blaming oneself when something bad happens. The ol’ “woulda coulda shoulda” guilt creeps in, and it’s easy to get focused on regrets. Even if the client really could have prevented a situation by changing their behavior earlier, it does no good to judge or blame once a diagnosis is made. A healthy internal locus of control is all about looking forward and determining what can be done to improve what is already happening.

I found myself nodding vigorously about this concept for two reasons in my own life. The first concerns my father’s bout with cancer. He had just about the strongest internal locus of control that I have ever seen. He ate healthy and exercised regularly, never smoked and raised us to believe that we had the ability to make our own destinies through hard work. And yet he got lung cancer. It happened to him, despite the fact that he had zero of the risk factors. I think that upset all of our perspectives – here was a man who did everything “right” and still faced one of the most devastating cases of stage IV cancer that many of our physician friends had ever seen. It was brutal. And when it came to his cancer, he deferred to his oncologist (the so-called expert – not!) on almost every decision and didn’t seem to believe anymore that independent decisions he made would make any difference. When my mom researched herbal remedies, for example, he refused to even discuss it with his doctor. When he was in the hospital with unmanageable pain, he trusted everything that came out of the oncologist’s mouth about additional treatment options and decided against hospice, while at the same time, that same a-hole doctor was telling my mom in the hall outside that Dad had a matter of weeks to live.

I think the pure terror of living with stage IV cancer is enough to make anyone give up a sense of control, especially because my father had taken such good care of himself and still got the disease. In a sense, sometimes your chances of getting sick are really just a crapshoot. It is absolutely crucial for nurses to get to the heart of how their clients feel about being sick, why they believe they got sick, and what they think they can (or can’t) do about it. Dad’s palliative care nurse was the first person to give him back some feeling of control by inviting him to participate in his own weekly case conferences. He got to sit in on speaker phone, ask questions, and offer opinions. Finally someone recognized his need to be treated with respect. And it was a nurse who did so.

My second example concerning loci of control is actually about me. I am an emotional eater. Always have been. It’s been a real struggle, especially because those of you who know me personally know what a hellhole my life has been over the past couple of years. That is where I am inconsistent when it comes to a locus of control. In almost every aspect of my life, I am internally-oriented and take full responsibility for my actions and their consequences. But when I can’t cope with something, food becomes my comfort. It makes no sense for someone so in control of her life to be so unhealthy. But that is my demon. And when I expressed concerns about this to my endocrinologist a few years ago, she brought in her med student to help with “patient education”, which was simply a 20-minute lecture on healthier eating habits.

I know intuitively how to eat healthy. I know what it takes, I know how to buy organic food, and I love to cook. It should be easy. But when it comes to my own locus of control, my perspective on food is completely screwed up. The first person to truly listen was a nurse practitioner, then a nurse midwife. And then my friends (especially S), who met me where I was, listened to me vent and continue to encourage me to make healthy decisions. And they walk with me every step of the way.

All this is to say… good nurses don’t judge and they don’t blame. They listen, they understand and they take the journey with you as far as they can go. And hopefully they empower you to keep it up.

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