As nurses, we promote health, encouraging people to lose weight, wear seat belts, quit smoking, eat right, and exercise more. We presume that people bear a great deal of responsibility for their own health and are capable of changing their behaviors—if only they would choose to do so.
Properly conveyed, this belief in the ability of people to change may empower and motivate them. They may no longer feel helpless or hopeless once they realize they're not simply victims of circumstance.
But we must be careful how we encourage people. For example, by saying, "Let's focus on the aspect of your weight issue that's within your control," a nurse is acknowledging the many dimensions of this problem and not making a blanket statement. We must be aware of both our underlying prejudices ("If she would just lose 100 pounds, her diabetes wouldn't be so out of control") and the danger of putting too much emphasis on patient responsibility, which can lead to an attitude that implies blame.
Patients sense the judgment of their health care providers. According to a 2008 survey conducted by Harris Interactive for the American Legacy Foundation, a nonprofit public health group, 21% of smokers didn't discuss their smoking with their health care provider. Of the smokers who did, 54% reported experiencing negative feelings—including unease, embarrassment, and guilt—about doing so.
Patients don't need messages of blame. In fact, many are already harsh enough on themselves. This was the case with "Jane" (her name and some details have been changed), a patient one of us (JN) cared for. Jane had undergone a thoracotomy for lung cancer, and although she rated her postoperative pain at 8 on a 10-point scale, she refused morphine.
"I don't deserve pain medicine," she said, explaining how she'd failed to quit smoking many times in the 35 years she'd smoked. "I'm paying the price for what I did."
But Jane's overwhelming sense of personal responsibility worked against her, threatening her recovery; it didn't empower or motivate her to make positive behavior changes.
Health care providers seeking to promote a sense of personal responsibility in patients must be aware of the following considerations.
Responsibility is complex. Situations and choices result from much more than autonomous and reasoned decision making. Choices and options may be constrained by past decisions, relationships, and habits. A patient may want to lose weight to lower her blood pressure, for example, but may also have a history of eating disorders that makes dieting in a healthful way challenging. Personal choice isn't solely a matter of willpower. We must compassionately explore the context of a health care concern and accept legitimate constraints on behavioral change.
Our own bias affects the care we provide. How do you feel about patients who "fail" to achieve health goals or who persistently make choices you consider wrong or unhealthy? Some of our bias comes from our own struggles and successes in regard to health. People who successfully manage their weight or have quit smoking, for example, may be less tolerant of those who seemingly can't.
We all need forgiveness and compassion. Few of us are the people we think we should be. We're all prone to error, self-deception, and failure to live up to our best intentions. We need to forgive ourselves and encourage patients to do the same.
Do we support the concept of personal responsibility? Of course. Are we against the use of this as a weapon to blame and demoralize? Absolutely. Nurses can and should encourage patients to be aware of the role they play in their own health, but they also need to demonstrate compassion, rejecting the temptation to blame and judge.© 2011 Lippincott Williams & Wilkins, Inc.