Difference in perception between nurses and patients related to patients health locus of control

bs_bs_banner International Journal of Nursing Practice 2014; 20: 242 249 RESEARCH PAPER Difference in perception between nurses and patients related to patients health locus of control Ayman M. Hamdan-Mansour RN MSN PhD Professor, Psychiatric & Mental Health Nursing, Department of Community Health Nursing, Faculty of Nursing, The University of Jordan, Amman, Jordan Lily R. Marmash RN MSc Lecturer, Psychiatric & Mental Health Nursing, Department of Community Health Nursing, Faculty of Nursing, The University of Jordan, Amman, Jordan Rana Alayyan RN MSN PhDc Head Nurse, Orthopedic and EENT Department, Jordan University Hospital, Amman, Jordan Saba Y. Hyarat RN BSN Registered Nurse, Department of Medical Surgical, King Abdullah University Hospital, Irbid, Jordan Accepted for publication January 2013 Hamdan-Mansour AM, Marmash LR, Alayyan R, Hyarat SY. International Journal of Nursing Practice 2014; 20: 242 249 Difference in perception between nurses and patients related to patients health locus of control Patient s health locus of control (HLOC) belief associates with superior health outcomes and patient satisfaction. Higher levels of HLOC beliefs among patients and nurses contribute positively in developing the partnership model of care. The purpose of this study was to examine the differences between nurses and patients perception of patient s health locus of control at the Jordanian general health-care settings. This study used cross-sectional, descriptive-correlation design to collect data using self-report questionnaires from 180 general nurses and 178 patients in general wards. Data collected were in regard to patient s perception of health locus of control. Patients and nurses expressed high level of externality and internality HLOC beliefs inferring the significance of partnership model of care. Chance was rated low among nurses and patients. The study emphasizes the role of nurses in enhancing their patient control and power over their health and participation in planning and implementation of health-care plans. Key words: externality, health locus of control, internality, Jordan, nurses. Correspondence: Ayman M. Hamdan-Mansour, Psychiatric & Mental Health Nursing, Department of Community Health Nursing, Faculty of Nursing, The University of Jordan, Amman 11942, Jordan. Email: a.mansour@ju.edu.jo This study was funded by the University of Jordan, grant number (55/2010 2011) INTRODUCTION Partnership between patients and health-care providers is considered an essential part of providing quality of nursing care. A number of studies reported that patients in different health-care settings want to assume more control and involvement in decision making. 1 Therefore, nurses are required to involve their patients in decision related to doi:10.1111/ijn.12132

Patients health locus of control 243 their health. This partnership relationship could be achieved through enhancing patient s internal health locus of control (HLOC). HLOC refers to the extent to which individuals believe that their health, particularly health outcomes, is controlled by forces that could be internal or external. 2 An individual who can determine events in his environment by his own action has an internally oriented LOC; on the other hand, an individual who thinks that the events in his environment are determined by outer forces like destiny and luck has an externally oriented LOC. 3 Studies proved that HLOC moderates health behaviours and adherence to health treatment plans. 4 For example, and among patients with cancer, high internal HLOC correlates positively with adoption of fighting spirit attitudes towards cancer and negatively with depression. 5,6 Whereas persons with high internality are more likely to desire control, deal effectively with health-related stressors, have ability to detect and prevent complications, and have positive perception of their quality of life. 7 10 In general, the literature shows positive impact of high levels of HLOC on patient s health outcomes. However, the available information related to the differences in perception of patient s HLOC between patients and their nurses received little attention in the literature. Previous studies focused on assessing patients locus of control 10 or health-care professionals perception of patients health locus of control, 1 or examining the differences in a specific issue of health-care treatment plan. 11 This study came to explore the differences between patients and nurses perception of patients HLOC. Agreement between nurses and patients on treatment plans and issues related to patients health that includes responsibilities and commitment is expected to reflect positively on the quality of care provided. Investigating the differences between patients and nurses perceptions of patients HLOC will allow understanding and recognizing the extent of partnership between patients and nurses in managing patients care. This will also be considered a means to investigate the foundation of partnership between nurses and their patients towards improving health outcomes. Thus, the purpose of this study was to examine the difference between patients and nurses perception of patient s HLOC at the Jordanian general health-care settings. The research questions were: 1. What is the difference between nurses and patients perception related to patient s health locus of control at the Jordanian general health-care settings? 2. Is there a difference in nurses perceptions and patients perceptions related to selected demographic and personal characteristics of each? METHODS Design This study utilized cross-sectional, descriptivecorrelational design to collect data from nurses and patients. Data were collected using self-reported questionnaires from general nurses and patients in Jordan, and in regard to patient s HLOC. Sample and setting A total of 180 nurses and 178 patients filled and returned the self-reported questionnaires. The sample recruited were from the three main health-care sectors in Jordan: educational, governmental and private. One hospital has been selected randomly from each sector. Nurses and patients were recruited using convenience sampling technique. Inclusion criterion for nurses is that she should have at least 6 months of working experience in the health field. For patients, the inclusion criteria were: (i) above the age of 18 years; (ii) admitted to general wards; and (iii) able to read and write in Arabic. Exclusion criterion is that if she had cognitive or physical disability that could affect her understanding or filling out of the survey. Data collection procedure Prior to data collection, the principal investigator obtained approval from the ethical committees at the Faculty of Nursing-University of Jordan, and the targeted institutions. Head of units of the targeted hospitals served as liaisons to facilitate approaching of both patients and nurses. A co-investigator was available during the distribution and receiving of the packages, so nurses and patients returned them directly to the co-investigator. The questionnaires were arranged in packages and only those who express interest in participation were asked to fill out the questionnaires. The package had a cover letter that includes information about the purpose of the study, what is expected from them, where to return the packages and that the study is anonymous. In addition, the cover letter included contact information of the principal investigator and co-investigators for any further information and for answering questions related to the study. It also included a statement informing the subjects that returning the questionnaire will be considered an approval to participate in the study. At the end of the cover letter there

244 AM Hamdan-Mansour et al. was a statement that asserts that their participation in the study is voluntary and their decision is of their own choice without any direct or indirect influence. Confidentiality was maintained throughout the study, and data were kept in a closed cabinet at the Faculty of Nursing, University of Jordan. Instrumentation The data were collected using an Arabic version of the self-reported questionnaires. After obtaining approval from the author to use the scale, a translation and validation translation were carried out by linguistic professionals for the medical terminologies, and a pilot testing of the instrument was performed to check for understanding, clarity and time required for filling the questionnaires. A number of procedures were used to determine the reliability and validity of the tool. The tool was first translated into Arabic language by a researcher and back-translated into English language by another independent researcher as described by Brislin 12 and Chapman and Carter. 13 The two English forms (the original and the translated) were compared in terms of conceptual rather than literal meaning of the items. The translator and the backtranslator met to examine the difference in the two forms. Pilot testing was conducted using nurses (n = 20) and patients (n = 20) requesting their appraisals for the appropriateness of the tool. In addition, an author-developed profile was used to obtain demographic and personal information from both nurses and patients. The instrument was the Multidimensional Health Locus of Control Scale (MHLC Form A) 14 used to examine HLOC of patients and nurses perception of patients HLOC. The scale is composed of three main subscales: internal subscale, chance and powerful others. The internal subscale was used to assess the degree to which individuals believed that their own behaviours affected their health outcomes. The powerful others subscale (external subscale) is used to assess the degree to which individuals believed that their health outcomes were dependent on powerful others such as doctors, nurses, family and friends. And the chance subscale is used to assess the degree to which patients believed that their health outcomes is due to chance. Each subscale contained six items with Likert responses, ranging from 1 (strongly disagree) to 6 (strongly agree), with a possible subscale score range of 6 36. Higher scores reflected stronger beliefs. The subscales were reportedly internally consistent with Cronbach s α ranging from 0.67 (external) to 0.77 (internal). 14 In this study, the language of the scale has been modified by a professional language editor to reflect the health professional s perception of patients HLOC. The scale showed good reliability, with Cronbach s α ranging from 0.72 (external subscale) to 0.81 (internal subscale). Covariates For nurses, personal details were obtained on participants age, gender, details about their nursing education, years in nursing, length of employment on current ward and length of employment in the nursing profession. For patients, information collected was on age, gender, medical diagnosis, length of stay at the hospital, number of admission to hospitals in the last 12 months, level of education, marital status and level of education. Data analysis Nurses perception of patient s HLOC and patients HLOC were described using the central tendency measures (means and medians) and the dispersion measures (standard deviation and ranges). The main variable of the study, locus of control, was described among each group and then compared. The obtained descriptive statistics were compared with other normative samples in the literature. Pearson correlation coefficient (Pearson r) was used to test the correlation between the selected variables. The t-test for two-independent samples was used to test for difference in perception of HLOC between nurses and patients. Also, t-test for two-independent samples and chi-square were used to examine the differences among groups in relation to selected demographic and personal factors. RESULTS Descriptive characteristics A total of 180 nurses and 178 patients completed and returned the questionnaire. For nurses (see Table 1), age ranged 22 52 years, with mean age of 27.5 (SD = 4.7). About 50% of them were between the ages of 24 and 26 years. There were 104 male nurses (57.8%) and 76 (42.2%) female nurses. Regarding patients, patients age ranged 18 88 years, with mean of 42.7 (SD = 15.9). About 50% of the patients were between the ages of 30 and 54 years. There were 94 male patients (52.2%) and 84 female patients (47.2%). Patients length of stay at the hospital ranged from 1 to 90 days, with mean of 7.5 days (SD = 10.0) and about 50% of them had length of stay ranging 2 8 days.

Patients health locus of control 245 Table 1 Demographic characteristics of nurses (n = 180) and patients (n = 178) Variable M SD Min Max n % Nurses Age in years 27.5 4.7 22 52 Years of experience 4.8 4.9 2 7 Gender Male 104 57.8 Female 76 42.2 Marital status Single 86 47.8 Married 92 51.1 Divorced 2 1.1 Level of education Diploma 13 7.2 Undergraduate 160 88.9 Graduate 6 3.3 Special course in Yes 40 22.2 therapeutic relationship No 138 76.7 Patients Age in years 42.7 15.9 18 88 Period of diagnosed in months 6.8 14.7 1 120 Number of admissions 3.2 4.1 1 30 Length of stay in days 7.5 10.0 1 90 Gender Male 94 52.8 Female 84 47.2 Marital status Single 49 27.5 Married 122 68.5 Divorced 1 0.6 Widow 2 1.1 Level of education Diploma 119 64.0 Undergraduate 51 28.7 Graduate 8 4.5 Patients HLOC Among patients, the analysis (see Table 2) showed that the mean score for the internal subscale was 21.4 (SD = 7.0); for the powerful others subscale it was 28.4 (SD = 8.1); and for chance subscale it was 18.5 (SD = 6.5). The results indicate that patients believed that their health outcomes were dependent on powerful others more than themselves or due to chance. The lowest mean score among the subscales was the chance subscale, inferring that patients believe that chance has a minimal role in determining their health outcomes. However, patients believed that others such as health professionals, family members and friends have more control on their health outcome than they do themselves. To find out which powerful others patients believe had the influence on their health outcome, extra analysis was done by examining the mean item scores for the powerful others subscale. The analysis showed that patients believed that health professionals have the highest control over their health outcome, with item means ranging from 4.4 (SD = 2.0) Whenever I don t feel well, I should consult a medically trained professional to 5.2 (SD = 4.7) Having regular contact with my physician is the best way for me to avoid illness. Whereas the item mean score for other people was low. The highest item mean score among the internal subscale was 4.2 (SD = 1.6) If I get sick, it is my own behavior which determines how soon I get well again, whereas the lowest was 2.6 (SD = 1.6) When I get sick, I am to blame. The chance highest item mean score was 4.8 (SD = 1.5) No matter what I do, I m likely to get sick, whereas the lowest item men score was 2.3 (SD = 1.6) Luck plays a big part in determining how soon I will recover from an illness. In conclusion, patients had strong belief that health professionals have the highest control over their health outcomes and that their health

246 AM Hamdan-Mansour et al. Table 2 Mean scores of health locus of control scale and subscales for of nurses (n = 180) and patients (n = 178) Variable Patients Nurses M SD M SD Patient total scale of health locus 68.1 16.2 55.3 14.7 of control Powerful other subscale 28.4 8.1 19.8 4.9 Highest reported item of the 4.2 4.7 4.3 1.2 Powerful other subscale Lowest reported item of the 4.4 2.0 2.2 2.5 Powerful other subscale Internal subscale 21.4 7.0 16.8 5.0 Highest reported item of the 4.2 1.6 4.3 2.7 Internal subscale Lowest reported item of the 2.6 1.5 1.9 0.8 Internal subscale Chance subscale 18.5 6.5 18.8 4.8 Highest reported item of the 4.8 1.5 4.5 1.6 Chance subscale Lowest reported item of the Chance subscale 2.3 1.6 1.8 0.4 is controlled by powerful others (health professionals) like friends, families, themselves or chance. Regarding nurses perception of patients HLOC, the analysis showed that the mean score for the subscales were as follows: internal subscale was 16.8 (SD = 5.0), the powerful others subscale was 19.8 (SD = 4.9) and chance subscale was 18.8 (SD = 4.8). The results indicate that nurses believed that patients health outcome is dependent on powerful others more than the patients themselves or due to chance. The mean item scores ranged from 1.8 (SD = 0.4) No matter what patient does, if he is going to get sick, he will get sick to 4.5 (SD = 1.6) Luck plays a big part in determining how soon patient will recover from an illness. In general, nurses perception is similar to their patient s perception that powerful others such as health professionals have greater influence on patients health outcome than patients themselves or chances do. The analysis also showed that the item mean scores of the powerful other subscale ranged from 2.2 (SD = 2.5) Health professionals control my health to 4.3 (SD = 1.2) My family has a lot to do with my becoming sick or staying healthy. Whereas for the internal subscale, the item mean scores ranged from 1.9 (SD = 0.8) If I get sick, it is my own behavior which determines how soon I get well again to 4.3 (SD = 2.7) The main thing which affects my health is what I myself do. Regarding the chance subscale, the item mean scores ranged from 1.8 (SD = 0.4) No matter what patient does, if he is going to get sick, he will get sick to 4.5 (SD = 1.6) Luck plays a big part in determining how soon patient will recover from an illness. To find out which powerful others nurses believe had the influence on patient s health outcome, the analysis showed that the mean score for health professional domain was 3.6 (SD = 1.5), whereas the mean score for the other people was 2.9 (SD = 1.5). This infers that nurses believed that health professionals have the greatest influence on the patients health outcome. As notes above, the items of chance subscale showed the lowest and highest mean scores. This means that nurses perception of the chance role in determining the patients health outcome is inconsistent. At a time they rate chance at the highest level and at other time they had very low rate. Differences between nurses and patients perception of patient HLOC To examine the differences between nurses and patient s perception of patients HLOC using t-test, the analysis (see Table 3) showed that there is a significant difference between nurses perception of patients perception (t = 2.20, P = 0.04) in the total score of the scale. The analysis also showed that patients mean score (3.8, SD = 0.91) was higher than nurses mean score (M = 3.07, SD = 0.95). Regarding subscales, the analysis (see Table 3) showed that there is a significant difference between nurses perception and patients perception of patients HLOC related to powerful others (t = 3.5, P = 0.017), whereas there were no significant differences between nurses and patients perceptions in chance and internal subscales (P > 0.05). The mean score for patients perception was also higher in the powerful others subscale (M = 4.7, SD = 0.28) than nurses mean scores (M = 3.3, SD = 0.93). This indicates that patients had higher perception of the role of health professionals and other people in determining their health outcome than their nurses do. Although both nurses and patients identified powerful others as the most influential element on patients health outcome, patients had higher perception than their nurses.

Patients health locus of control 247 Table 3. Mean item differences between nurses and patients perception of patient s health locus of control (nurses = 180, patients = 178) Variable n M SD Test statistics t-test P-value Health locus of control total scale Patients 178 3.81 0.91 2.2 0.042 Nurses 180 3.07 0.95 Internal subscale Patients 178 3.59 0.54 1.54 0.185 Nurses 180 2.80 0.90 Chance subscale Patients 178 3.11 0.91 0.001 0.950 Nurses 180 3.11 1.11 Powerful others subscale Patients 178 4.72 0.28 3.54 0.017 Nurses 180 3.29 0.93 Differences in HLOC related to demographic characteristics Regarding differences in nurses perception in patients HLOC in relation to demographic characteristics, the analysis showed that there were no significant differences between nurses in regard to age, gender, marital status and educational level (P > 0.05). The analysis also showed that there was a significant and positive correlation between nurses perception of patients HLOC and nurses years of experience in nursing profession (r = 0.19, P < 0.001). Regarding differences in patients perception of HLOC in relation to their demographic characteristics, the analysis showed that there were no significant differences in patients perception in regard to age, gender, marital status, educational level, number of times of admission, length of stay at the hospital and period in months being diagnosed with the current disease (P > 0.05). In summary, demographic characteristics have no contribution to nurses and patients perception of patient s HLOC. DISCUSSION HLOC beliefs influence patients health behaviours and illustrate how dependent the patients are on themselves, their health professionals or on chance in managing their health. Equally, nurses perceptions of patients HLOC have implications for whether nurses encourage patients to play an active role in managing their health or having their patients depend on them or on chance. Therefore, partnership requires that both patients and nurses have an agreement on how a health-care plan should be achieved. High agreement will reflect the efforts made by nurses and patients to enhance partnership in health-care plan and management. In this study, patients reports showed that patients had high level of perception that their health outcomes depend primarily on their health professional, family and friends, whereas nurses had lower level of that perception. Among all the powerful others in patients life, patients identified health professionals to be the most influential one. However, patients reported higher level of internality than nurses did, implying that patients believed that their health outcomes were secondly determined by their own behaviours. Both nurses and patients had almost equal level of perception about the role of chance in determining patients health outcomes. The results, in general, showed that there is not much agreement between patients and nurses on determinants of patients health outcomes. This indicates that the concept of partnership in nursing care delivery is not well developed. Thus, more attention to elements of partnership in the health-care system is needed, particularly patients and nurses perception of HLOC. The results of this study agree with a previous international study that reported that both patients and health-care professionals had high rates of external and internal HLOC. 11 Their study supports the theme of dual health locus of control. The typology of dual HLOC speaks that patients have high level of external (powerful others) and internal HLOC. Dual HLOC is found to have positive impact on patients with chronic illnesses. 15,16 Others viewed dual HLOC as an advantage to health-care professionals as patients will collaborate effectively with them if they have higher level of externality and internality. 17 Moreover, patients and nurses agreement reflect a mutual perception. According

248 AM Hamdan-Mansour et al. to Auerbach and colleagues, 7 health outcomes are better when there are agreement on the health-care responsibilities between patients and their health-care professionals. In addition, nurses and patients in this study rated externality as the most influential factor on patients health outcome and much higher than internality and chance. The results do not agree with previous study that reported that patients had higher perception of internality than externality, although the internality perception among patients was higher than nurses perception of patients internal HLOC. 11 One explanation is the immature development of partnership between patients and health professionals in the health-care system in Jordan and similarly in the Arab world. Patients are not yet allowed to be equivalent partners in health-care planning. Moreover, the health-care system in Jordan does not recognize the role of patients in health-care planning. This might result in forming patients perception that their health outcomes are determined primarily by their health professionals. This study also found that nurses with more years of experience had higher perception of patients HLOC. One explanation could be related to the type of responsibilities that nurses are acquiring with more years of experience, and the positive role of nurses in empowering patients to take an effective role in their health-care planning. Nurses with longer years of experience play a significant role in forming positive perception of HLOC, and therefore, have the ability to integrate elements of partnership in their daily care plans and interventions. CONCLUSION This study found that nurses and patients agree that patients health outcomes are primarily dependent on health professionals. Patients had higher reports than nurses in regards to internality and externality health HLOC. The study provided evidence that dual health locus of control beliefs and practices are significant contributors to a patient s positive health outcomes. The study has implication for health-care providers, and particularly nurses. Nurses should recognize that their patients are not passive recipients and rather have a high level of awareness about their role and contribution to their health outcomes. Nurses are required to enhance partnership in health-care planning and integrate that into their daily care plans and interventions. Nurses need to empower patients to take an effective role in health-care planning through enhancing patients internality. Patients are also aware of the significant role of their health-care professionals on their health outcomes. Therefore, nurses are required to provide support for their patients autonomy. 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