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Keywords:

  • emotional labour;
  • difficult communication;
  • so-called difficult patients;
  • home nurses;
  • avoidance;
  • strategy (emotional distance);
  • compromise strategy;
  • persuasion strategy;
  • qualitative study;
  • hermeneutic phenomenology

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Selected literature
  5. Method
  6. Findings
  7. Discussion
  8. Further research and implications for practise
  9. Conclusion
  10. Acknowledgements
  11. Funding
  12. Ethical approval
  13. References

Scand J Caring Sci; 2012; 26; 90–97

Emotional distance to so-called difficult patients

Purpose:  To explore nurses’ relationships with patients they regard as being difficult. How do nurses feel about such patients and relate to them, and what are the consequences for nurse and patient?

Design and methods:  A qualitative study inspired by hermeneutic phenomenology was conducted. The data were obtained through participant observation and interviewing in a home nursing unit in a Danish municipality. During an initial 3 month period, eighteen participant observations were conducted with 12 nurses during their visits to 96 patients. During the following 3 months, 12 more participant observations were made with three nurses visiting 50 patients. Four of these patients whom the three nurses found difficult were selected and six interviews conducted with these patients. Eleven interviews were conducted with five nurses. Patients’ case records were studied and four meetings with the staff were arranged to discuss the findings. Data collection lasted 18 months in all.

Findings:  Three strategies were identified: persuasion, avoidance (emotional distance), and compromise. Interestingly, in the relationship with a particular patient, the avoidance strategy did not necessarily represent the terminal stage, since a nurse could revert to the compromise strategy. Some of the nurses experienced painful emotions regarding these interactions.

Conclusions:  The avoidance strategy (emotional distance) resulted in important social and health problems of some patients not being recognized, and some nurses using it expressed the fear of losing contact with their emotional lives. The compromise strategy gave possibilities for dialogue.

Study limitations:  The focus was mainly on the nurses and their perspectives. It would be interesting to study in greater detail the perspectives of the patients.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Selected literature
  5. Method
  6. Findings
  7. Discussion
  8. Further research and implications for practise
  9. Conclusion
  10. Acknowledgements
  11. Funding
  12. Ethical approval
  13. References

This article explores nurses’ relationships with ‘difficult patients’, that is patients the nurses regard as difficult. It presents a qualitative study of communication between home nurses and patients, and investigates how nurses feel about and relate to such patients, and what the consequences are for patient and nurse. The concept of the ‘difficult patient’ used in this article does not imply that these patients are in fact difficult. Previously, data collected as part of the same project have been used to understand the phenomenon of the ‘difficult’ patient. This showed that a particular patient may be regarded as difficult by one nurse but not by another, and consequently there is no unequivocal definition of a ‘difficult’ patient. The difficulty did not lie in the patient, but in the relationship between the nurse and the patient (1, 2). Since the nurses were deeply concerned about their relation to the difficult patients it is relevant also to explore nurses’ relationships with these patients.

Selected literature

  1. Top of page
  2. Abstract
  3. Introduction
  4. Selected literature
  5. Method
  6. Findings
  7. Discussion
  8. Further research and implications for practise
  9. Conclusion
  10. Acknowledgements
  11. Funding
  12. Ethical approval
  13. References

This section briefly summarizes relevant previous work on difficult patients, emotional labour, distancing strategies in nursing and communicative aspects of the nurse-patient relationship.

‘Difficult patients’

Research shows that patients may be labelled as difficult if they do not do what the staff tells them, if they cannot be controlled by them, if they ask too many questions, or if they constantly interrupt the professionals’ routines (3, 4). Studies show that nurses are provoked by patients who are overweight, addicted, e.g., to medicine or cigarettes (5, 6), and that physicians are provoked by patients’ characteristics, e.g., if they are demanding, non-compliant, aggressive or hostile. Physicians are also frustrated by being unable to cope with these patients’ medical situations, i.e., to diagnose or treat their conditions (7–9). Smith and Hart (10) discuss how nurses label patients as ‘difficult’ when their behaviour challenges the nurses’ emotional control of patient care. Research shows that negative emotions, in either nurse or patient, make communication more difficult (11). Limited attention has been given to ‘difficult patient’–nurse relationships (12) and to the nurse’s responses to difficult patient behaviours (13).

Emotional labour

Smith (14) found that nurses had to induce, suppress or subordinate their own feelings to make patients feel cared for and safe, and analysed this using the concept of ‘emotional labour’. Hochschild defines emotional labour as ‘the management of feeling to create a publicly observable facial and bodily display’ (15: 7), a kind of work that requires that one induces or suppresses feeling in order to create the right atmosphere in others. Emotional labour is a part of nursing, and carries with it the risk of the nurse becoming detached or alienated from her feelings. It has been pointed out that emotional labour often is seen as a tacit and uncodified skill, and that further research in this area is needed (16). Hochschild has analysed flight attendants who, in common with many other professionals, are socialized to identify with and engage themselves in other people. She finds emotional labour potentially good; as she says, no customer wants to deal with a flight attendant who avoids eye contact in order to avoid getting a request, but she raises the question of what the cost of emotional labour is. In order to survive, the flight attendant must mentally detach herself from her own feelings and the management of them. Some ways of performing emotional labour may be likened to acting. In surface acting one disguises what one feels, and pretends to feel what one does not – one deceives others about what one feels, but not oneself, since one is conscious of it. This is also referred to as a ‘healthy’ estrangement, e.g., the flight attendant pretends to be happy (and sometimes she gets the feeling), and the passenger reacts as if the flight attendant were happy. In deep acting one tries to feel what one senses one ought to feel or wants to feel, and one focuses on what to do to induce the feeling. Perhaps one feels angry, but this is experienced as not allowed, and therefore one tries not to act openly on the feeling; e.g., the flight attendant who suppresses her anger at a passenger who insults her. She might try to induce in herself the feeling that the passenger is like a child who drinks too much because of fear of flying, and then she does not get angry if he shouts at her. In deep acting one deceives not only others but also oneself. By deep acting the flight attendant alters herself. The concept of emotional labour, with surface- and deep-acting, is central in analysing and discussing one of the nurses’ strategies, ‘emotional distance’ and its consequences for their emotional lives.

Distancing strategies in nursing

Health care professionals use distancing strategies during difficult interactions through fear of being unable to handle their own negative emotions (17). Nurses who disconnect during challenging interactions with a patient may be unable to communicate with this patient (10). When a high level of interaction does not result in the patient adopting the expected norms for behaviour, the nurse avoids the patient physically and/or psychologically (18). In addition, emotional labour and emotional engagement or detachment are in the words of Henderson (19), ‘under-theorized’ in relation to caring work in general.

Communicative aspects of the nurse-patient relationship

Travelbee has discussed nurse-patient communication in terms of a human-to-human relationship (20). This consists of four phases: Original encounter, emerging identities, empathy and sympathy. Through these phases, mutual understanding is reached so that nurse and patient can relate as unique human beings rather than as nurse and patient. Sympathy is defined as an experience between two or several individuals, with the capacity to take an active interest in another person’s feelings. According to Travelbee it is not possible to both sympathize and keep a distance at the same time. Two elements in Travelbee’s work have inspired the discussion in this article about communication in nursing: sympathy as an important element in the nurse-patient relationship, and the perception of this relationship as a human-to-human relationship.

To summarize, the literature on how the nurse behaves when responding to difficult patient behaviours is scanty. According to the literature, emotional labour and emotional engagement or detachment are under-theorized in relation to caring work in general. In this article nurses’ relations to patients they find difficult are analysed and discussed with focus on consequences for both nurse and patient.

Method

  1. Top of page
  2. Abstract
  3. Introduction
  4. Selected literature
  5. Method
  6. Findings
  7. Discussion
  8. Further research and implications for practise
  9. Conclusion
  10. Acknowledgements
  11. Funding
  12. Ethical approval
  13. References

Theoretical frame

Hermeneutic phenomenology is grounded in phenomenological philosophy. Phenomenology, founded by Husserl, is the study of the life world with the aim of gaining a deeper understanding of the nature or meaning of everyday experiences (21). Hermeneutic phenomenology is both a descriptive (phenomenological) methodology because it is attentive to how things appear, and an interpretive (hermeneutic) one, because it claims that no uninterpreted phenomena exist. This is explained in the following way: ‘the (phenomenological) “facts” of lived experience are always meaningfully (hermeneutically) experienced. Moreover, even the “facts” of lived experience need to be captured in language (the human science text), and this is inevitably an interpretive process’ (21: 180–181). If one is a strict follower of Husserl, one may insist that phenomenological research is pure description and that interpretation (hermeneutics) falls outside the bounds of phenomenological research. However some philosophers make a distinction between phenomenology (as pure description of lived experience) and hermeneutics (as interpretation of experience via some ‘text’ or via some symbolic form), e.g. Silverman distinguishes between interpretive or hermeneutic phenomenology and descriptive phenomenology (22). An interpretive phenomenological framework is well suited for the present purpose of searching for the meaning of the nurses’ experiences. One way to study human actions and to search for understanding of the experiences is to participate in and observe the nursing care situation and to interview in order to obtain a person’s own narrative. In the following, participants, participant observation, interviews and analysis will be presented.

Participants

Nurses.  The study took place in the home nursing unit of a Danish municipality with 50 nurses and in the patients’ homes. The twelve nurses in the initial participant observations were between 32 and 63 years old. The nurses selected for formal interviews were 32, 35, 45, 50, and 63 years old, and one of them male. All had several years of nursing experience. Inclusion criteria regarding the initial participant observations were the nurses’ willingness to participate. Inclusion criteria for the subsequent 12 observations were that the nurses had taken part in the initial observations, that they were willing to continue participating, and that they had had at least 2 years’ home nursing experience. Other criteria were that they had been the head or deputy head nurse of a district, that they visited patients they found difficult, and that they had at least 1 year’s experience with the selected patients. Inclusion criteria for interviews were that a nurse had had experience with the selected patients, and was willing to be interviewed.

Patients.  The patients during the initial participant observations were from 40 to 90 years old, and most were around 80 and female. Finally, with advice from the nurses, 4 patients (three female and one male) out of 50 were selected for interviews. All four patients lived alone. One was 60 years old, suffering from diabetes and heart insufficiency. Another patient, who was 80 years old, suffered from rheumatism. A third patient was 90 years old and suffered from a slipped disc. The fourth patient was 60 years old, and suffered from arthritis. Inclusion criteria for interviews were that the patients were regarded as difficult by a nurse, that they had received home nursing for at least 2 years, that they were willing to participate, that they neither suffered from memory loss nor were senile, and that they were not in crisis.

Data collection

The data were obtained through participant observation and interviewing (formal and informal). During an initial 3 month period, eighteen participant observations were conducted with 12 nurses during their visits to 96 patients. During the following 3 months, 12 more participant observations were made with three nurses visiting 50 patients with whom the nurses had experienced communication problems. Four of these patients were selected, and six interviews conducted with them. 11 interviews were conducted with five nurses – the three who found the selected patients difficult and two other nurses with long experience of the selected patients. Patients were interviewed in their homes, and nurses were interviewed in the nursing unit or, in the case of one nurse, in her home. Patients’ case records were studied and four meetings with the staff were arranged to discuss the findings. Data collection lasted 18 months in all.

Participant observations.  ‘Moderate participant observation’, where the investigator keeps a balance between being an ‘insider’ and an ‘outsider’, between participation and observation, was the research method used to observe the verbal and non-verbal communication. During home visits the investigator primarily observed unless contacted or questioned (23). An observation lasted for about 3–4 hours. Field notes of the communication were made with a description of the situation, the informal interviews, a preliminary analysis, interpretations, ideas and new questions. The purpose of the initial observations was to understand nurses’ experiences in general with patients, and to select nurses for further observations. The next 12 observations focused on how these nurses managed their relationships, especially with patients they regarded as difficult. In consultation with the nurses, patients they regarded as difficult were selected for interviews.

Interviews.  Informal interviews, e.g., with a nurse on the way from one patient to another during participant observations, were made without an interview guide. The formal interviews were conducted with a semi-structured interview guide containing themes and questions inspired by the purpose of the study and by the continual analysis. The interview guide was used to varying degrees, depending on how the interview proceeded. An interview lasted for about 1–2 hours. All interviews were audio-taped, transcribed verbatim, and analysed. The purpose of interviewing the nurses was to understand their feelings about and relations to patients they regarded as difficult. The purpose of interviewing the patients was primarily to elucidate their experiences with and expectations of the nurses, and to obtain a deeper understanding of the patients for comparison with the nurses’ descriptions. The unit of analysis was mainly the interviews with the five nurses.

Analysis

The first part of the analysis was characterized by decontextualisation, governed by the purpose of the study, and began immediately after the first data (participant observations of nurses visiting patients) had been collected. One observation or interview was analysed before the next one took place. The text was read and reread, and tentative thoughts were recorded. The investigator’s preconceptions of the phenomenon under study (bracketing) were clarified. To minimize biases, presuppositions were listed and discussed with a research colleague who was not a nurse. The material was divided into meaning units focusing on what the text said without questioning or looking for a deeper meaning in the statements. Data were condensed (24). Meaning units were allotted a theme based on the informant’s own expressions with a focus on the unique, the individual, the common, and on the extreme. Themes from, e.g., an interview, created the frame for a continual reading, but the analysis was open for new themes to be revealed. The goal was to find common themes. The various data e.g., the emotions of different nurses as expressed in interviews were compared and contrasted with one another, and observations were also compared with interviews. What was found was viewed in the context of the nurses’ working conditions and private lives. Bracketing is neither possible nor desirable in the hermeneutic approach used in the last stage of the analysis, which is characterized by recontextualisation. The focus then was on how the text could be understood in the context of the purpose of the study, not on what the text said. One of the guiding principles in this interpretation was to consider each part of the text in relationship to the whole (25). The theme ‘emotional distance’ was related to theoretical concepts about nurse –‘difficult patient’ relationships and nurses’ reactions to difficult patients as well as to sociological theories of emotional labour. Finally all the data were compared. The result was a higher-level synthesis, a description and an interpretation of the world of the informants seen in relation to the purpose of the study.

Ethical aspects

Ethical clearance of the study was obtained from The Bioethics Commitees for the Capital Region of Denmark, Copenhagen, and consent was given by the patients and home nurses; in addition, special consent was given by the patients to study their case records. All identifiers regarding both patient and nurse were removed before analysis. In referring to both patients and nurses the personal pronoun ‘she’ is used irrespective of gender to avoid problems with lack of anonymity. Nurses felt isolated with their problems and focusing on phenomena such as ‘difficult-patient’ and ‘emotional distance’ brought up embarrassment in the nurses. It was important to give feedback, especially since these issues were not a subject for discussion within the nursing unit.

Findings

  1. Top of page
  2. Abstract
  3. Introduction
  4. Selected literature
  5. Method
  6. Findings
  7. Discussion
  8. Further research and implications for practise
  9. Conclusion
  10. Acknowledgements
  11. Funding
  12. Ethical approval
  13. References

Nurses’ relations to and feelings about ‘difficult’ patients

Both the behavioural and the emotional reactions of the nurses could be classified as three different strategies which will be referred to as ‘persuasion’, ‘compromise’, and ‘avoidance’. A given nurse did not always use the same strategy, but could change from one to another. Examples of the strategies will be presented, together with the nurses’ descriptions of their feelings.

Persuasion.  The persuasion strategy was characterized by the nurse believing that the patient would accept advice and instruction, and attempting to get the patient to adjust to the patient role expected by the nurse (compliance). This could be done in different ways, ranging from giving advice to threatening. This strategy was described in the nurses’ jargon as ‘to fight against the patient’ or ‘to speak out loud and play ones trump card’:

There have been periods where she sat down and was unwilling to do anything. I have been one of those who have had to raise my voice. It has not always been pleasant. If she does not agree to a weight-loss programme and does not want physiotherapy, then she has to go to a nursing home because we will not be able to look after her at home, simply because she is too heavy. Three people will not be able to get her up on her feet.

The nurse tries to persuade the patient by frightening her and refusing to let her return home from hospital if she does not accept advice and instruction about losing weight, but feels bad about raising her voice. In another example the nurse tries to persuade the patient to accept her illness by confronting her:

She does not want to be confronted with being ill. She misses a lot of things, and when you try to find solutions, she will not accept them. She does not want to use a bedpan, and she does not want to use a wheelchair. When I tell her “You must acknowledge that you are so ill”, then she is not ill. She is all right. Then she switches off, she becomes a cold fish, you cannot reach her.

Further examples of this strategy are given below in connection with nurses who use more than one strategy.

Avoidance.  This strategy, emotional distance, was in nurse jargon called ‘passing the buck’ or ‘being a cold cigar’, in a literal translation of the Danish, which corresponds in English to ‘being a cold fish’, and appeared to be one of the nurses’ survival strategies. The avoidance strategy was characterized by the nurse increasing the emotional distance to the patient, by withdrawing either psychologically, (not being emotionally present in the situation), or physically, (by asking a colleague to take over), a nurse reaction with more or less negative feelings towards the patient and with a greater or lesser distance to the patient. In some situations the distance was further increased by the patient demanding care and contact, e.g., when the patient wished to continue talking, the nurse avoided relating to this, quickly dosed the medicine, and left. The nurse uses avoidance with a bad conscience because, at the professional level, she chooses to avoid seeing problems the patient might have:

I can stand her now because I have reached the level where I just come in, say something or other, and leave again. When I wanted to obtain a greater understanding of her in order to be able to give her some opportunities, I couldn’t stand her. I have given up, you get nowhere. I am a cold fish when visiting her, but I am also afraid that I do not see things that I ought to.

Another nurse has given up completely in relation to another patient, and just wants to get out as quickly as possible:

I leave her in a hurry, because I can use my time much better somewhere else. I could motivate her to do this or that, but she will do exactly as she pleases. I think as the years go by one uses ones energy elsewhere.

In a way it is a relief that a nurse can make a patient laugh:

She is one of those that my colleague cannot stand, so very often it is nurse X and I who take over. I believe that she is happy to see us, so it does not bother me that I am the one who visits her most. I think she has a sad life, so if I can make her laugh a bit then it is better.

However, laughter can also be a strategy to make a distance to the patient’s problems. Besides laughter and humour, the nurse uses fear, e.g., in connection with the open sores on the legs:

But she rejects the sores on her legs and behaves as if they were mine! This is what irritates me, something that is the most difficult thing about patients. Sometimes I can say: “That leg is yours not mine!” If she is not ready to help herself, then I cannot heal it. I have those standard sentences: “I don’t care because I have got a steady job”. Now and then this can frighten people to do what I want!

There seems to be no dialogue, and the nurse is irritated. During the participant observations this patient disagrees with the nurse about the treatment of the legs. The patient clearly asks for an exercise bike to improve her circulatory system and thereby heal the wounds, but this request is ignored by the nurse. The nurse says clearly that frightening is perceived of as a way of making an emotional distance to the patient. During the visit she talks extremely loudly and is almost impossible to interrupt, a fact that, taken together with the other observations, may be understood as a way of avoiding a dialogue. Another nurse, in relation to the same patient, also uses emotional distance, but she is aware that this can be a way of escaping instead of engaging:

If you like your job, you get involved. I am not very good at making contact with my friends, and it remains that way, this is at that level, but I don’t wish to go further into this, because I know what I have and what I do not have. It has not always been easy, not at all! Then it is a great pleasure to care a little and, in quotes “to be interested”. In relation to some of the patients I do not get in contact. I have other patients that I am more interested in, but still in a distant way. That is where I feel the escape, where one should be able to engage in deeper relationships and not only with your husband.

This nurse is conscious of the fact that she does not get involved with the patients, that she avoids engaging in deeper relationships, and that there is a risk that some of the patients’ problems are not discovered. She realizes that her understanding of patients with whom she cannot communicate is limited. She talks about professional distance while still caring, and expresses conflict with ideals for caring and nursing, among other things to engage deeply in human relationships.

Compromise.  This strategy was in the nurses’ jargon called ‘not digging’. The compromise strategy was characterized by the nurse finding a compromise between using persuasion and avoidance. The nurse had given up trying to get the patient to be compliant, but had not gone so far as to avoid the patient. This situation could last for a long time, but could also change. The nurse accepted that the patient did not listen to her, and she did not question what the patient said. The following examples show transition and oscillation between strategies. One example of moving from persuasion to compromise:

I asked her whether she wanted to go to a physiotherapist, and she agreed, but actually nothing happened. Then I must admit that I have done nothing ever since, because she is not able to appreciate the effect of the exercise programme. She accepts her fate and we have to live with that.

The nurses have tried without success to make this patient lose weight. Some nurses still try, but this nurse has given up and seems to accept the situation. Another nurse oscillates between avoidance and compromise by listening, because she is convinced that the patient is in crisis. During the process of gathering the data, the patient and the nurse never seem to develop a relationship:

In general she does not stress me, but I can create an emotional distance that is of no benefit to her. Sometimes I choose to do this if I feel I cannot do anything else. But today I really wanted to communicate with her. I can imagine that she is not able to get out of the crisis herself.

A third nurse moves from avoidance to compromise with the same patient. At the beginning of the relationship the nurse wanted to leave quickly since she could not stand the continual complaints about pain:

She was a patient I would ask another nurse to take over, since it was too difficult and irritating. You felt you were giving medicine to a drug addict. I remember at the beginning that I wanted to get out again as quickly as possible. I could not stand this, but this changed as we built up a relationship. If you focus on the medicine the whole time, you will get an irritating woman who just wants her pills. If you turn it around and say “This situation is not interesting, and you know it. What are we supposed to do with one another?” you might get another sort of information. Little by little we changed our relationship. When I came to visit, the pills were ready on the dinner table, and she had made tea.

This nurse manages to create a relationship, never rejecting the patient’s complaints. The nurse asks about the pains, contacts the physician in order to give a little extra medicine, and is of the opinion that nurses more often should let patients administer their medicine themselves.

Patients’ expectations

In general, the patients seem to be satisfied with the nurses, and do not seem to have high expectations. At the same time, they appear to be in doubt about what the nurses are supposed to offer. One patient does not want to talk about illness with the nurses. In her view this is done with the physician and communication with the nurse is expected to be about what happens in society in general. Another patient says that she cannot communicate because one of the nurses talks too much. A third patient expects the nurse to tell her if the patient is doing something wrong, but does not regard this as the nurse’s duty.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Selected literature
  5. Method
  6. Findings
  7. Discussion
  8. Further research and implications for practise
  9. Conclusion
  10. Acknowledgements
  11. Funding
  12. Ethical approval
  13. References

Methods

Many studies of difficult patient-provider relationships have identified these by means of questionnaires. This method gives information on the extent of the problem, but does not explore explicit relationships in depth, which was the purpose of this study. Participant observations and interviews were useful methods for illuminating the phenomenon under study. It was possible to experience and understand the phenomenon where it took place, in the patients’ homes, as well as narrated. Use of observations as the sole data source risks emphasising the researcher’s subjective perspective. To reduce that risk, participant observational studies are often followed by interviews (26), as was done here.

Findings

Consequences of nurses’ emotional distance for patients.  The emotional distance caused the nurse to see the patient through a filter. For some patients, this resulted in the nurse concentrating on the physical aspects of illness and a lack of interest in the patient’s view of the causes of illness in the context of their lives. In one case the avoidance strategy resulted in serious physical symptoms being overlooked. Previous research has shown that nursing that does not take care of the patients’ physical needs results in their becoming frustrated and angry and feeling isolated (6, 12, 18).

Consequences of emotional distance for nurses.  Nurses’ reactions to patients they regard as difficult have consequences not only for the patients but also for nurses’ families: research has shown that nurses caring for difficult patients react by being aggressive to their own families (6). The findings in this article show that the avoidance strategy carries with it an increased risk of the nurse becoming emotionally fossilized. Seen from the perspectives of nurses’ ideals for nursing one would expect nurses to be able to distinguish themselves from their job, like the group of flight attendants who knew when they were acting and when not. In the participant observations there are examples of nurses reacting in a way in which it appears that they are no longer able to clearly distinguish between themselves and the role. For example, a situation was observed where a nurse did not seem to be emotionally in contact with a patient, even though, before visiting the patient, she described herself as having such contact. Precisely in this context the emotional distance becomes interesting. Where the above-mentioned flight attendants clearly decided when they were acting or not acting, the emotional distance of the nurse in this case could be interpreted as estrangement from her feelings.

Emotional distance may be perceived as an appropriate way of dealing with the demands of, e.g., nursing, because it acts as a defence against becoming overloaded by work. As one nurse described it, she was conscious of an emotional distance to the patients when she did not possess the resources to address their problems. Emotional distance may also be seen as an inappropriate defence, because the nurses obviously do not experience any relief of the situation. Some of the nurses stated in the interviews that the emotional distance meant that they were afraid of not recognizing important aspects of the patients’ needs, and some expressed the fear of becoming emotionally detached. Constantly facing situations that a person cannot deal with can create stress, which may cause illness (27). Some of the nurses out of the initial 12 selected ones for participant observations suffered from serious illnesses, e.g., cancer and heart disease, but this was not characteristic for the five interviewed nurses of the present study. Working conditions are often in contrast to the flexibility and spontaneity which is a prerequisite for emotional labour, e.g. constant restructuring in the home nursing unit can make it difficult to perform emotional labour. Working conditions seem to contribute to create difficulty in the nurse-patient encounter (28). There was a gulf between home nurses’ ideals and the possibilities for realizing them. This disparity carries with it the risk of the nurse losing control of or access to her feelings, which in turn can lead to burnout, described as a personal consequence for professionals working with emotional labour (29). However the selected nurses for the present study did not seem to suffer from burnout.

Possibilities in the compromise strategy.  Emotional distance does not have to be the terminal stage. The present study shows that, where communication is possible to some degree, this can change into the compromise strategy. This strategy may be perceived of as an expression of the patient’s power, as well as of the nurse giving up trying to keep the patient in the role of a patient. Thus it has potential in caring for patients perceived as difficult because it is characterized by the nurse showing a certain tolerance, a positive attitude and flexibility. It opens up for dialogue and thereby gives the possibility for perceptions to be changed, as has recently been found in the context of physiotherapy (30). According to Travelbee, the human-to-human relationship model is not possible without sympathy, and it is not possible to have sympathy and at the same time to keep a distance to a particular patient. Furthermore communication is not possible if sympathy does not lead to mutual understanding (20). Perhaps it should be accepted in nursing that mutual understanding is not always possible, and that different levels of sympathy exist. Travelbee defines communication as ‘a process which can enable the nurse to establish a human-to-human relationship and thereby fulfil the purpose of nursing, namely, to assist individuals and families to prevent and to cope with the experience of illness and suffering and, if necessary, to assist them to find meaning in these experiences’ (20: 123). One may ask whether Travelbee’s definition of communication is somewhat one-sided, in that it is the nurse who establishes the relationship, but what about the patient? Travelbee’s idea about dissolving the nurse-patient roles (to establish the human-to-human relationship) is interesting but it does not seem to take into account the inherently asymmetric power relation between nurse and patient.

Further research and implications for practise

  1. Top of page
  2. Abstract
  3. Introduction
  4. Selected literature
  5. Method
  6. Findings
  7. Discussion
  8. Further research and implications for practise
  9. Conclusion
  10. Acknowledgements
  11. Funding
  12. Ethical approval
  13. References

It would be valuable to carry out research focused on ‘successful communication’, as experienced by the patient as well as by the nurse. Working conditions must be improved, and it would be useful to discuss the above-mentioned power relations as well as different attitudes to and goals in nursing. According to Travelbee, it is not possible to simulate sympathy even with the most advanced communication techniques. However one step would be to dare to admit the negative feelings, talk about them, react on them, and ask another colleague to communicate with the patient. Different strategies to develop the interaction are suggested in the nursing literature e.g.: ‘Therapeutic communication’, ‘Scenario-based learning’ and ‘Supervision’ (13, 31, 32). There are many ways in which nurses could be motivated to focus on the so-called difficult patient’s story, which can be seen as especially interesting and challenging because it could pinpoint areas on which professionals should focus to a greater degree.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Selected literature
  5. Method
  6. Findings
  7. Discussion
  8. Further research and implications for practise
  9. Conclusion
  10. Acknowledgements
  11. Funding
  12. Ethical approval
  13. References

Three types of strategies adopted by home nurses in relation to patients they found difficult were identified: persuasion, compromise, and avoidance (emotional distance). The strategies characterized both behavioural and emotional reactions to the patient. Interestingly, avoidance did not necessarily represent the terminal stage, since a nurse could revert to compromise with possibilities for dialogue. With respect to avoidance, this resulted in important social and health problems of some patients being overlooked. Other consequences of this strategy were a concentration on the physical treatment of the illness, and lack of interest in the patient’s view. Some nurses expressed fear of losing control of their emotional lives.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Selected literature
  5. Method
  6. Findings
  7. Discussion
  8. Further research and implications for practise
  9. Conclusion
  10. Acknowledgements
  11. Funding
  12. Ethical approval
  13. References

The author wishes to thank the patients and home nurses who participated in this study. A special word of thanks is due to Professor Liora Bresler, University of Illinois at Urbana-Champaign (UIUC).

Funding

  1. Top of page
  2. Abstract
  3. Introduction
  4. Selected literature
  5. Method
  6. Findings
  7. Discussion
  8. Further research and implications for practise
  9. Conclusion
  10. Acknowledgements
  11. Funding
  12. Ethical approval
  13. References

This study was funded by the Danish National Health Research Foundation (ref.nr:12-0579-1 kg/mp) and by the Danish Research Academy (J.nr:V910202).

Ethical approval

  1. Top of page
  2. Abstract
  3. Introduction
  4. Selected literature
  5. Method
  6. Findings
  7. Discussion
  8. Further research and implications for practise
  9. Conclusion
  10. Acknowledgements
  11. Funding
  12. Ethical approval
  13. References

Ethical approval was obtained from The Bioethics Committees for the Capital Region of Denmark (reference number: KA 91242, KWK/bt).

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Selected literature
  5. Method
  6. Findings
  7. Discussion
  8. Further research and implications for practise
  9. Conclusion
  10. Acknowledgements
  11. Funding
  12. Ethical approval
  13. References
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