Abstract
Communication in the Primary Health-Care Sector. A Qualitative
Investigation of Relationship and Interaction between
Home Nurse and the “Difficult” Patient.
This thesis presents a study of the relationships between home nurses and what they call “difficult” patients in a Danish municipality north of Copenhagen. The purpose of the study is to analyze and understand the phenomenon of the “difficult” patient. Why are some patients regarded as difficult by some nurses, what strategies do nurses adopt to cope with these patients, and what are the consequences of these strategies? One possible reason that could contribute to a patient being labelled as “difficult”is differing views of the causes of illness, and, in order to explore this possibility, a further aim is to analyze nurses’ and patients’ perceptions of the causes of illness. The data for the investigation, which is based on qualitative research methods, were obtained by participant observation and interviews with home nurses and “difficult” patients. The study focuses on the nurse-patient relationships that the home nurses found difficult. The findings are analysed in relation to theories of emotional labour, of perceptions of health and illness, and of nurses’ reactions to patients. The investigation shows that a particular patient may be regarded as difficult by one home nurse but not by another, and consequently it is not possible to make an unequivocal definition of a “difficult” patient. The difficulty lies not in the patient, but in the relationship between the home nurse and the patient. The patients regarded by home nurses as being difficult had in common that they were mainly chronically ill, and, in the view of the nurses, denied that they were ill, had little insight into their illness, and were not compliant. Some nurses had negative feelings about their patient, regarded the patient as too demanding in terms of resources, or found the patient’s personal characteristics repulsive. Other contributing factors include working conditions for the nurse, the nurse’s personal life, class differences between nurse and patient, the patient’s illness provoking anxiety in the nurse, and differences between the nurse’s and the patient’s views of the causes of illness. The study shows that the nurses construe the patient in a manner that distances the communication problems from themselves as persons, and to a large extent also from the political, social, cultural, and economic context in which home nursing is carried out. Three types of strategy adopted by home nurses in relation to patients they found difficult were identified: adjustment, avoidance (emotional distance), and compromise. The strategies characterized both behavioural and emotional reactions to the patient. Interestingly, in the relationship with a particular patient, the avoidance strategy did not necessarily represent the end-point, since a nurse could revert to the compromise strategy. With respect to the avoidance strategy, this resulted in important social and health problems of some patients not being recognized. Other consequences of this strategy were a concentration on the physical aspects of the illness, and lack of interest in the patient’s view. In some cases the strategy resulted in the persistence of the nurse’s view of a patient as difficult. For some nurses the emotional distance held the risk of their losing contact with their emotional lives. Perceptions of the causes of disease were also investigated. At a general level both nurses’ and patients’ explanations were dominated by psycho-social and psychological ones, rather than ones in terms of isolated biochemical processes in the body. However at the specific level, there were differences, in that a nurse could use an explanation for, e.g., alcoholism of a member of her family, but would regard this as inapplicable to a patient the nurse found difficult. In addition, nurses sometimes regarded an illness as “self-inflicted”, while the patient viewed it as a result of his life and social condition
Investigation of Relationship and Interaction between
Home Nurse and the “Difficult” Patient.
This thesis presents a study of the relationships between home nurses and what they call “difficult” patients in a Danish municipality north of Copenhagen. The purpose of the study is to analyze and understand the phenomenon of the “difficult” patient. Why are some patients regarded as difficult by some nurses, what strategies do nurses adopt to cope with these patients, and what are the consequences of these strategies? One possible reason that could contribute to a patient being labelled as “difficult”is differing views of the causes of illness, and, in order to explore this possibility, a further aim is to analyze nurses’ and patients’ perceptions of the causes of illness. The data for the investigation, which is based on qualitative research methods, were obtained by participant observation and interviews with home nurses and “difficult” patients. The study focuses on the nurse-patient relationships that the home nurses found difficult. The findings are analysed in relation to theories of emotional labour, of perceptions of health and illness, and of nurses’ reactions to patients. The investigation shows that a particular patient may be regarded as difficult by one home nurse but not by another, and consequently it is not possible to make an unequivocal definition of a “difficult” patient. The difficulty lies not in the patient, but in the relationship between the home nurse and the patient. The patients regarded by home nurses as being difficult had in common that they were mainly chronically ill, and, in the view of the nurses, denied that they were ill, had little insight into their illness, and were not compliant. Some nurses had negative feelings about their patient, regarded the patient as too demanding in terms of resources, or found the patient’s personal characteristics repulsive. Other contributing factors include working conditions for the nurse, the nurse’s personal life, class differences between nurse and patient, the patient’s illness provoking anxiety in the nurse, and differences between the nurse’s and the patient’s views of the causes of illness. The study shows that the nurses construe the patient in a manner that distances the communication problems from themselves as persons, and to a large extent also from the political, social, cultural, and economic context in which home nursing is carried out. Three types of strategy adopted by home nurses in relation to patients they found difficult were identified: adjustment, avoidance (emotional distance), and compromise. The strategies characterized both behavioural and emotional reactions to the patient. Interestingly, in the relationship with a particular patient, the avoidance strategy did not necessarily represent the end-point, since a nurse could revert to the compromise strategy. With respect to the avoidance strategy, this resulted in important social and health problems of some patients not being recognized. Other consequences of this strategy were a concentration on the physical aspects of the illness, and lack of interest in the patient’s view. In some cases the strategy resulted in the persistence of the nurse’s view of a patient as difficult. For some nurses the emotional distance held the risk of their losing contact with their emotional lives. Perceptions of the causes of disease were also investigated. At a general level both nurses’ and patients’ explanations were dominated by psycho-social and psychological ones, rather than ones in terms of isolated biochemical processes in the body. However at the specific level, there were differences, in that a nurse could use an explanation for, e.g., alcoholism of a member of her family, but would regard this as inapplicable to a patient the nurse found difficult. In addition, nurses sometimes regarded an illness as “self-inflicted”, while the patient viewed it as a result of his life and social condition
| Original language | English |
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| Place of Publication | Århus |
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| Publisher | Danmarks Sygeplejerskehøjskole |
| Number of pages | 185 |
| Publication status | Published - 1999 |
