‘Eyes can tell you more’: the importance of face-to-face contacts
Policlinics specialised in delivering care to chronic heart-failure patients discharged from hospital but still in need of care have been established in the mid-1990s. These clinics can thus be considered as a rather recent innovation in health care. The heart-failure clinic investigated in this study was founded in 2001 by Medical Spectrum Twente (MST), the main general hospital in Enschede in the Netherlands. Currently, all major Dutch hospitals run a heart-failure policlinic as part of their regular health-care services. The emergence of the heart-failure policlinics coincided with the rise of a new specialty in nursing: heart-failure nursing (Anonymous 2004:8,9). In most Dutch academic and general hospitals, care traditionally given by cardiologists has been partly delegated to this new category of nurses. In the past decade, heart-failure nursing has developed into a profession with a high degree of autonomy in which nurses can advise, educate, supervise, diagnose and treat heart-failure patients (Anonymous 2004:10).
Currently, the heart-failure policlinic at the MST hospital provides care to approximately 650 patients, which include elderly but also younger patients, and is run by three qualified nurses assisted by a research physician and supervised by a cardiologist (Interview heart-failure nurse B). Heart-failure patients are referred to the policlinic when they are discharged from hospital, particularly those patients admitted to the hospital because of asthma cardiale: severe breathing problems caused by redundant fluid that impairs the expansion of the lungs. A first consultation at the policlinic consists of anamnesis (a short history of the development of the disease), explanation of the disease, measuring blood pressure and weight5, giving advice concerning a healthy life style, and prescription of medication. Follow-up consultations consist of monitoring the health condition of patients and their compliance with medication and the bodily regime (Inspectie gezondheidszorg 2003:14).
To perform the multiple tasks involved in a consultation in the policlinic, nurses can rely on various resources to assess the conditions of patients, including an electronic patient record, measurement of weight and blood pressure, laboratory tests, and observation of the patient. The interviews with the nurses at the heart-failure policlinic show that visual cues are valued as crucial. Nurses emphasized the importance of ‘seeing the patient’. Or as one nurse put it:
The looks of a patient can tell you how they are doing . . . I want to see how tight in the chest he is, how swollen his legs or how blue his hands or lips are. I want to see it (Interview heart-failure nurse A).
As has been described for other nurses (Johnson-Mekota et al. 2001; Pettinari and Jessopp, 2001), the heart-failure nurses in the policlinic experience nursing as a profession with a visual attitude, although listening to patients to detect shortness of breath is considered as important as well. In the stories nurses told us, they easily switched between visual and auditory cues as important elements in their assessment:
Nurses are very much attuned to vision. This is what you learn in your training: ‘are there changes, do you notice anything when you look at the patient? Does he have swollen feet? Is he short of breath?’ You listen to the patient. You just look at the patient (Interview heart-failure nurse C).
Although auditory resources thus play a role in the evaluation of patients’ accounts of their illness, nurses prioritise visual cues. According to nurses, patients may often tell them they are doing fine, also when they have swollen feet or breathing problems:
Sometimes patients don't tell you what is wrong, simply because they don't want to be ill . . . In the policlinic I can see them. Maybe very simple, but this is how it is (Interview heart-failure nurse C).
Visual resources are considered as even more important than the objective measurement of blood pressure:
Look, a blood pressure tells you a lot, but not everything. Someone can have a nice blood pressure but look very miserable. A blood pressure does not reveal that. Therefore you want to keep seeing your patients. Eyes can always tell you more than . . . (Interview heart-failure nurse B).
Visual cues are thus valued more than other resources, particularly in those cases in which nurses detect contradictions with the measurements of bodily indicators or the accounts of patients (Interview heart-failure nurses B and C).
The ‘crying policlinic’: knowing the patient and psycho-social care
Physical proximity at the heart-failure clinic is not only important to monitor the physical condition of patients but plays other important roles as well. First, physical nearness enables nurses to communicate with patients with hearing deficiencies or patients who don't speak the Dutch language, particularly elderly immigrants from Turkey and Morocco. In face-to-face contacts with these patients, nurses can rely on non-verbal communication, or ‘talking with your hands and feet’ (Interview heart-failure nurse B). Physical encounters at the heart-failure clinic also enable recently immigrant patients to invite an interpreter, often a close relative, to accompany him/her to the consultation (Interview heart-failure nurse B).
Secondly, physical proximity enables nurses to build a relationship with patients, or as one nurse put it:
I simply realised that a tie arises between patients and us as heart-failure nurses. It is definitely different from the cardiology department in the hospital. You have much more time for people. People trust you very much (Interview heart-failure nurse C).
These close relationships between nurses and patients play an important role in lowering the threshold for patients to call nurses in case they gain weight or experience breathing problems. This is important because an early detection of the problem may prevent immediate hospitalisation (Interview cardiologist A). Knowing patients personally also plays an important role in learning to interprete patients’ accounts of their illness. Because of the wide variety in which patients voice their complaints, ranging from exaggerating to underestimating heart-failure symptoms, nurses have to rely on their knowledge of patients’ characters to decide how they should evaluate a patient's story.
As with nurses, cardiologists also consider it as crucial to ‘know the patient’, not only to interpret the ways in which they voice their complaints but also to differentiate between the various ways in which heart-failure symptoms are expressed by patients, and even value this more than actually seeing the patient:
If I have seen the patient several times, and I know the patient, then you can tell ‘this is the weak spot of the patient’. If you know patients then you can tell that if they are not doing well they don't eat any more. Another patient will be more short of breath. If you know these nuances of patients I can tell by phone, without seeing him, that he should visit the clinic (Interview cardiologist A).
Coming to know the patient thus seems to take place particularly during face-to-face contacts at the beginning of the care trajectory. If relationships with patients are well-established, ‘seeing the patient’ becomes less important and a first assessment of the seriousness of patients’ complaints can be done by phone. What all these experiences indicate is that physical proximity enables nurses to come to know the patient as a person as well as his/her illness. This is in line with Malone's argument that physical proximity is important to create narrative proximity, a term she introduced to refer to processes in which ‘nurses come to “know the patient”, by hearing and trying to understand the patients’ story’ (Malone 2003: 2318). Narrative proximity can thus be considered as an important aspect of nursing at the heart-failure policlinic and is crucial for the kind of care provided at this clinic.
Finally, physical proximity enables nurses to give support to patients to cope with the disease. The diagnosis of heart-failure has severe consequences for patients. They not only have to change their lifestyle and diet, take their medicines regularly, or measure their weight and blood pressure daily, they also have to learn to come to terms with the eventual fatal consequences of the disease. Learning to cope with the disease may involve intensive psycho-social stress for which patients often cannot find adequate support in their own environment. Therefore, heart-failure clinics consider the provision of psycho-social support as central to the care they give to patients. Actually, psycho-social care can be considered as one of the major achievements of heart-failure policlinics. Prior to the existence of these outpatients’ departments, care for heart-failure patients was restricted to medical care (Interview heart-failure nurse A). Psycho-social care is not only provided to patients but also given to their close relatives. Close relatives, often the partner, are explicitly invited to accompany patients to consultations at the heart-failure policlinic. Nurses thus have to take care of emotions of patients and their partners. Consultations at the heart-failure policlinic often involve expressions of strong emotions and a lot of crying. Consequently, the heart-failure policlinic is often referred to as the ‘crying policlinic’ (Interview heart-failure nurse A). Psycho-social care is not only provided at the policlinic; nurses also organise thematic afternoons and refer patients and their partners, often separately, to social workers at the hospital (Interview heart-failure nurse A). Contacts with partners of patients also provide nurses with an extra resource to come to know what the illness means in daily life for the patient and her/his family, including problems related to compliance to the bodily regime and medication. Patients’ partners are thus crucial to realise the two aspects of narrative proximity as described by Malone: they inform nurses about the illness of the patient, and, vice versa, nurses can transmit their knowledge to ‘others’, in this case partners who care for patients. Actually, heart-failure nurses go even one step further. They not only transmit their knowledge to partners, but also invite them to play an active role in the care for patients, particularly to help (male) patients keep to their diet. Nurses thus enrol partners as important intermediaries to extend their span of control over patients’ compliance to the patients’ home. As the provision of psycho-social care, the involvement of partners in care is one of the major achievements of the heart-failure policlinic
Summarising, we can conclude that the physical proximity to patients created in the policlinic facilitates a contextualised and personalised care: patients are approached as part of a relational setting and care plans are attuned to the character and life style of the patients. In this form of care, nurses act as counselors of patients and have a high degree of autonomy. Responsibilities for monitoring, including diagnosis, supervision and treatment, are delegated primarily to nurses.