The purpose of this article is to describe a concept of shared control between the nurse as health-care provider and the recipient/client and demonstrate its potential, positive effects in terms of client morale, satisfaction, and compliance with health maintenance regimens. Although the concept of shared control is applicable to a variety of health-care providers, recipients, and settings, this article focuses on its use by nurses with geriatric clients in community settings.
Control is denned as "to exercise restraining or directing influence over; to have power over" (Webster's New Collegiate Dictionary, 1981, p 245). Such terminology describes the historical posture of health-care providers toward recipients of their care. The very concept of "doctor's orders" acknowledges the authoritarian attitude held by medical practitioners. Unfortunately, the adoption of the concept of "nursing orders" by some nurses further evidences this attitude.
Elderly health-care recipients, having already experienced loss of control over many aspects of their lives, often view health-care regimens and treatments as dictatorial mandates further eroding their power of self-determination. In addition, chronic illnesses and lifelong behavioral patterns are not readily amiable to a "cure it" approach. Therefore, health-care providers often become frustrated when elderly clients don't respond to treatment. And, elderly clients may avoid seeking needed health-care interventions due to negatively perceived outcomes. However, nurse and client interactions designed to optimize the client's control in the decision- making process strengthen client autonomy and increase the probability of client compliance resulting in positive outcomes.
Functioning as a facilitator, the nurse encourages and supports clients' decisions regarding their care. This nursing role requires flexibility and willingness to work with elderly toward meeting goals which clients perceive as attainable as well as desirable.
The Issue of Control Parameters of Control
The concept of decision-making control can be viewed as on a continuum from that of no control to that of absolute control. Related to relationships and interaction between nurse and client, decision-making control can be conceptualized as falling somewhere between the two extremes of the continuum.
Nurse _____________ Client Absolute Control Absolute Control
Nurse-client interactions situated on the far left of the continuum foster client dependencies. As interactions aimed at increasing client's decision-making control move toward the right on the continuum, client independency is enhanced.
Many factors determine the exact point on the continuum that control should be located in any given situation. Competencies, cognitions, perceptions and role expectations of nurse and client will influence the decisionmaking control each maintains throughout the interactive process. However, all too often control is exercised by providers of health care to the far left on the continuum, irrespective of client wishes or capabilities. The nurse can guide clients in moving toward the opposite direction on the continuum by supporting client decision-making autonomy, thereby increasing client compliance, satisfaction, self-esteem and independence.
Effects of Control on Client Morale, Satisfaction, and Compliance
The issue of shared control between provider and recipient of health-care services was studied by Glazer.1 The results demonstrate that nurses and consumers viewed patient participation in care important, while physicians did not. In fact, physicians did not even perceive that a patient should understand his/her problem "which is a necessary part of active participation in one's care."1 Glazer's study showed that contemporary consumers want to understand and participate in their care, have new expectations about their role as patient, and that nurses should actively involve consumers in all aspects of their care.
Several studies relating concepts of control to client/patient morale, life satisfaction, self-esteem and compliance to therapeutic regimens have each found a positive relationship between these variables and perceived control on the part of health-care recipients.2'4 In examining several characteristics of the elderly receiving intermediate and skilled care, Ryden found "Perception of situational control was a key variable, significantly related to the morale of residents on both levels of care. "2
Abramson, Seligman, and Teasdale distinguished "personal helplessness" from "universal helplessness"3 in relating these human feelings to self-esteem and depression. "Situations in which subjects believe they cannot solve soluble problems are instances of personal helplessness;" and "situations in which subjects believe that neither they nor relevant others can solve the problems are instances of universal helplessness."3
Health-care recipients can be viewed in both types of situations, experiencing both personal and universal helplessness. When clients are not allowed to participate in problem-solving decisions involving their own care, they will likely experience personal helplessness. When neither recipient nor provider of health care can solve problems, universal helplessness is evidenced.
Although both forms of helplessness can lead to disruptive behavior, Abramson, Seligman, and Teasdale found that "depressed individuals who believe their helplessness is personal show lower self-esteem than individuals who believe their helplessness is universal."3
It is this form of client's "personal" helplessness that nurses can effect positive change by allowing clients more control in nurse-client relationships, thus enhancing client selfesteem.
Closely paralleling the concepts of personal and universal helplessness is that of locus of control which "refers to individual's beliefs about whether or not a contingency relationship exists between their behavior (actions) and their reinforcements (outcomes).4 An internal locus of control is evidenced when individuals believe they have control over situational outcomes. External locus of control is evidenced in situations where individuals do not believe they control outcomes but that others, outside themselves, maintain this control.
Citing both positive and negative correlation studies between locus of control and client compliant behaviors, Shillinger4 reviewed research dealing with locus of control and health behaviors. She believed that "all too often a person's experience with the health-care system is coercive, thereby restricting the individual's need to fully direct and control his life affairs freely, which in turn leads potentially to noncompliance behaviors."4 She advocates a balanced internal-external orientation, whereby clients are self-reliant but seek external assistance when appropriate in meeting health-care goals.
Chang5 developed a tool to measure patient perceptions of situational control over their activities of daily living. Utilizing this Situational Control of Daily Activities (SCDA) tool, she concluded "Th Use of the SCDA in a study of elderly persons in skilled nursing facilities shows that self-determined SCDA was the strongest contributor to the variance of morale."5
In searching for concepts and theory relating control to gerontological nursing, a positive correlation was found between client motivation, participation in physical activity, and increased self-esteem.6 The author postulated that self-esteem was a prerequisite for client-perceived control and well being.
From the above discussion, it would seem evident that health-care recipients would benefit in terms of heightened morale, self-esteem, and satisfaction and an increase in compliance to care regimens when they are afforded more control in health-care situations, specifically those involving nurse-client situations and relationships. This could be accomplished by the nurse viewing the client as a partner with sharing of control, and assuming an advocacy role in guiding clients toward self-determination in decisions and activities involving their care.
The Advocacy Role for the Nurse
The concept of advocacy is important if nurses are to move from an authoritarian role to one based on a relationship model more in keeping with elderly clients' best interest, conducive to their well-being. The advocacy role of the nurse has been studied by Kohnke7 who stresses the following point related to the concept of shared control between nurse and client: "The role of the advocate is to inform the client and then to support him in whatever decision he makes."7 Recognizing hazards in advocacy for both client and nurse, Kohnke states that "the most important attributes for the advocate to possess, for the safety of both, are a state of open-mindedness and a broad knowledge base about people, society and the social order."7
The nurse working with elderly clients in community health settings is in an advantageous position to function as client advocate and share decisionmaking power with clients. Methods by which this control can be a shared experience between nurse-advocate and client are the substance of an interaction model based upon this writer's conceptualization of nurse-client relationships which incorporates concepts of lmogene King's theory of goal attainment.8 Nurse-Client Relationships and Practices
MODEL FOR SHARED CONTROL BY NURSE AND ELDERLY CLIENT IN COMMUNITY CARE SETTINGS
King's theory for nursing8 is one whereby nurse and client interact to mutually establish goals, explore options and agree on means to achieve these goals. Mutual goal setting is based on the nurse's assessment of clients' concerns, problems and disturbances in health, as well as clients' perceptions of their problems and situations. The desired outcome in nurse-client interaction is goal attainment.8 King's theory describes a nurseclient relationship whereby control is a shared responsibility. This theory, along with the concept of role-advocacy for the nurse and the concept of decision-making control being on a continuum ranging from zero to absolute, is the basis of this author's model depicting control as a shared experience between nurse and elderly client.
The model consists of a process in which the nurse and client interact through six progressive modules. In each module, specific activities and responsibilities of both nurse and client interplay to arrive at specific outcomes. Should incongruence occur at any point in this process, interactions must revert to a former module whereby differences can be resolved.
Throughout the six modules, control of decision making and activities involved can be adjusted according to client needs and capabilities. Evaluation, although listed as the last module in this model, is an actual ongoing process whenever judgments and decisions are made by both nurse and client. The following outlines the six modules, activities involved in each, and expected outcomes.
Application of Model to Clinical Practice
The shared control model has been used with elderly clients having a variety of health-care problems and has been effective in promoting desired behaviors. The following describes the model's use in modifying noncompliant behavior of an 80-year-old man who tailed to take prescribed antihypertensive medication on a consistent basis.
Mr. G, an elderly widower, lived alone in an apartment complex. Although capable of meeting his daily living needs, he believed his health status to be his "doctor's responsibility" and admitted to sometimes "forgetting to take his blood pressure pill." After assessing Mr. G's lifestyle for activities and health behaviors that might be affecting his blood pressure, the nurse reviewed hypertension and prescribed medication with expected outcomes. In addition, the nurse clarified roles of health-care providers, stressed client responsibility for controlling his blood pressure, and explained the nurse's role as one of assisting Mr. G to accomplish his goal.
At the conclusion of Phase One, Mr. G was not ready to accept full responsibility for blood pressure control and doubted he could remember to take his medication "every day." At this point, perceived client control was judged to be minimal. Therefore, the nurse accepted temporary partial control in the situation.
The nurse and Mr. G reviewed past and present blood pressure recordings which evidenced a pattern of blood pressure control/noncontrol, and the client admitted that perhaps his pressure "went up when he forgot his medicine." A nursing diagnosis of partial noncompliance was explained, along with supporting data and possible consequences of continuing present behaviors regarding medication regimens. After reviewing the diagnosis and Mr. G's present status, the client agreed that the diagnosis accurately described his situation.
Both nurse and client identified the desired goal as consistent maintenance of blood pressure control as evidenced by blood pressure recordings of 160 or less systolic and 90 or less diastolic. Mr. G agreed that his goal was to remember to take his medication on a daily basis.
In exploring options to meet identified goals, Mr. G continued to voice some concerns about his ability to "remember" to take his medicine. Various reminders were explored. The nurse agreed to support and assist by 1) making a daily medication schedule/ calendar covering one-month period of time and posting it in a prominent place; and 2) monitoring Mr. G's blood pressure and medication compliance twice weekly for two weeks and then weekly for two more weeks. During each visit, the nurse would check the medication calendar and count Mr. G's blood pressure pills. Mr. G agreed to get a neighbor friend to telephone him every day for one week to remind him to take his medicine and to cross off each day on his calendar when he took his medicine. A written contract, specifying activities each agreed to perform, was signed by both nurse and client.
During the one-month time period both parties fulfilled their contractual agreement. At each nurse-client encounter, the nurse offered positive reinforcement for Mr. G's compliance and reviewed additional health behaviors conducive to blood pressure control.
At the end of the one-month trial period, Mr. G's blood pressure recordings met the specified criteria as stated in the goal and both parties agreed to terminate the relationship. Mr. G decided to continue to use a calendar in helping him "keep up with his medicine." Subsequent follow-up visits evidenced Mr. G's continued compliance.
Although the above scenario is perhaps an oversimplification of the events presented, it nevertheless depicts advantages for the health-care provider and client in mutually identifying problems, goals, needed actions for goal attainment, and expected outcomes. The desire and necessity of the elderly to assume more control and responsibility over their health status and health behaviors serve as the underlying factors in the interaction model.
- 1 . Glazer G: The good patient. Nursing and Heallh Care 1981; 2(3):144-147. 164.
- 2. Ryden MB: Morale and perceived control in institutionalized elderly. Nursing Research 1983; 33(3):130-136.
- 3. Abramson LY, Seligman MEP. Teasdale JD: Learned helplessness in humans: Critique and reformulation. Journal of Abnorm Psychol 1978; 87(l):49-74.
- 4. Shillinger FL: Locus of control: Implications for clinical nursing practice. Image :The Journal cf Nursing Scholarship l98ì;l5(2):58-63.
- 5. Chang BL: ftrceived situational control of daily activities: A new tool. Res Nurs Health 1978; I(4):18J-188.
- 6. Collins RM: Toward a theory of gerontologicai nursing. Nursing and Health Care 1982; 3(10):550-556.
- 7. Kohnke MF: Advocacy, what is it? Nursing and Health Care 1982; 3(6):314-318.
- 8. King IM: A Theory for Nursing. New York, John Wiley & Sons, 1981.
MODEL FOR SHARED CONTROL BY NURSE AND ELDERLY CLIENT IN COMMUNITY CARE SETTINGS