The Unpopular Patient Revisited
Characteristics or Traits of Patients which may result in their being considered as ‘Difficult’ by Nurses
Padraic Conway MSc BA RGN RCNT Cert. Ed
Senior Lecturer, University of Teesside School of Health
Paper presented at the Qualitative Evidence-based Practice Conference, Coventry University, May 15-17 2000
Abstract
A review of the literature supports the concept of the "difficult" patient (see Stockwell, 1972 and English and Morse, 1988). This concept is based upon the premise that the patient in question departs in some fashion from set norms established by staff of anticipated patient behaviour. Deviation from this set role by patients may result in patient avoidance by nursing staff (Carveth, 1995).
This work, undertaken in 1996, clarifies the local meaning of the “difficult” patient amongst staff in two areas with elderly in-patients. Focus-groups are used to gather data, and a grounded theory approach is employed for data analysis.
Data analysis highlights some confusion between ‘difficult’ and ‘difficult to nurse’ .In some cases ‘difficulty’ may be due, at least in part, to diagnosis, such as stroke. ‘Difficult’ behaviour is identified, described, and the resulting perceptions of staff are discussed. A framework termed ‘Patient Rules’ is derived from the staff’s reactions to these behaviours. Whilst previous studies suggest that nursing staff have a common understanding of what constitutes difficult patient behaviour, some justification is offered here that the issue is more complex, and that patient ‘difficulty’ is a relative, as opposed to absolute, quality.
The growth of patient consumerism is noted, as are the influences of the Patients’ Charter , and both can be argued to profoundly alter the traditional nurse-patient relationship. Implications for practice are suggested, and directions for further study are offered.
Introduction and Justification
Stockwell first discussed the ‘Unpopular Patient’ in 1972. The widely held contemporary view that nurses treated all patients in a non-judgmental fashion was challenged. It would appear that the construct of the ‘difficult’ patient has not been widely addressed within the U.K. since then. A re-investigation into this field is timely, considering the changes in healthcare that have occurred in the interim, including initiatives to empower patients, delivering quality care, and a move towards meeting customer's needs.
Aims of the Study
1To identify ‘difficult’ and ‘non-difficult’ patients from the perspectives of nursing staff.
2To define personal characteristics of individual patients which contribute to the classifications above.
3To determine the relative importance given by nurses to differing patient’s characteristics in this classification process.
Literature Review
Any researcher in this field should be aware that much available literature is either anecdotal (Diekelmann 1992; Egan 1987; Roberts 1987), or originates from North America, where the context of care delivery differs in important aspects from the UK (Podrasky and Sexton 1988). Kelly and May (1982) provide a compendium of studies, but more recent UK work is hard to find.
Space precludes a full debate of all relevant work here, but Stockwell's work in 1972 provides a very useful starting point when trying to decipher the subtleties and variations of the use of the term ‘difficult’ as applied to patients by nurses. She prefers the term ‘unpopular’ in her work, defined as "patients whom the nursing team enjoys caring for less than others" (Stockwell, 1972 p.11). This definition has been considered synonymous with the later use of the term ‘difficult’ by other authors. Stockwell aimed to devise means of identifying popular and unpopular patients in general wards; to identify factors that may account for the popularity and unpopularity of patients and to ascertain whether the degree of popularity influenced any aspects of care delivered.
‘Difficult’ related specifically to intervention by nurses
Some patient unpopularity relates specifically to situations or behaviours where the patients' actions or attitudes have clashed with nursing interventions. Stockwell concludes that patient’s attributes such as a lengthy stay in hospital, or previous hospitalisations make a contribution to patient unpopularity. This idea is also found in Orlando (1961) who proposes a link between patients who take longer to recover than the staff anticipate, and their being perceived as difficult. Orlando also indicates that patients who interrupt the planned workload of staff may also be likewise perceived.
English and Morse (1988) adopt an ethnoscientific approach to the investigation of the "Difficult Elderly" patient. They used anecdotal accounts as well as nurses' letters to journals, and subjected them to a content analysis; 42 such scenarios were used. These instances are incorporated into a simultaneous triangulation with interviews of both staff and patients about their perceptions of the issue. This is the only instance in the literature reviewed where triangulation with patients is attempted. The patients' responses indicated that difficult behaviour tended to be a result of nursing staff attempting to over-exert their control; resulting in a clash with the patients' expectations of the management of a given situation.
Jeffery (1979) focuses on specific groups of patients (drunks and tramps), who had already been identified as unpopular before the study. In this case non-participative observation and interviewing were used for data collection. Data analysis produces a clear model of acceptable patient behaviour within Accident and Emergency nursing; a model that was shared by all staff, and contravention of which produced an unpopular patient. This construct would appear to be derived from that of Parsons (1951).
Interestingly, Melanson and Downe-Wamboldt (1985) identify unfavourable stereotyping of the elderly by student nurses occurring in a similar fashion to that identified by Jeffery, thus providing an indication that cautious generalisation of his findings outside of trauma settings may be justified.
The relationship with patient diagnosis or condition
A further category into which terms used to indicate patient unpopularity fall is a diagnostic classification. The elderly (Melanson and Downe-Wamboldt 1985), stroke patients (Gibbon 1991) as well as back pain (Strong, Ashton, Chant and Cramond (1994) can be cited here. Condition- and behaviour-related uses of the term ‘difficulty’ are therefore possible. It should also be remembered that the two uses could overlap, or indeed be applied concurrently to the same individual. Kestler (1991) provides an account of this occurring with orthopaedic patients.
Undertaking a local study about ‘Patient Difficulty’
Data Collection
Focus groups were selected as the means of data collection. The intention was to encourage staff to share their constructs of patient difficulty with the researcher and each other. While this method has not been widely employed in nursing before, it has been undertaken elsewhere by ethnographers seeking to understand the culture and values of discrete groups (Saint-Germain, Bassford and Montano 1993; Bach and Daniel 1993; Tessaro, Eng and Smith 1994). Four such groups were undertaken, involving a total of eighteen staff as contributors. The first two focus groups also utilised card sorting as an ‘icebreaking’ exercise.
Two additional group sessions were also organised. These were not primarily for the purposes of gathering further data, although they were recorded, and some new data was gathered. These sessions had a double purpose: preliminary data categories (derived from the transcripts of all four tapes) were presented to the groups for discussion purposes to assess their trustworthiness (Kuzel and Like 1991), and the meetings also served to de-brief participants involved in the process.
Sampling
Sampling was essentially judgmental, with areas selected on the basis of the literature review. Medical or elderly wards were felt to be most appropriate as patients in these environments have a relatively lengthy hospital stay. Previous findings have suggested that the length of patient stay is influential in the attribution of the term "difficult" by nurses (Stockwell 1972). Additionally, other workers (English and Morse 1988) have shown the elderly to be potentially "difficult". Staff participation was dependent upon the ward workload on each day, and was therefore impossible to predict in advance. Participants were generally a mixture of relatively young qualified staff, and mature care assistants. Some student nurses also participated. Miles and Huberman (1994 p.266) specifically advocate including respondents of all status groups in order to avoid a site bias upon the researcher.
Ethical Issues
Participant recruitment was addressed by briefing interested ward staff with regards to the aim of the study and the ethical implications. An invitation to these briefing sessions was extended to all staff. This researcher felt obligated to report any reported sanctions to managers in order to safeguard the interests of current patients (UKCC 1992). All would-be participants were explicitly informed of this prior to the sessions. This could easily have inhibited contributors to the groups, but here this researcher was not comfortable with the “truthful but vague” approach employed by Lankshear (1993) when briefing focus groups.
The Local Ethics Committee granted ethical approval for the study in June 1995.
Analysing the Data
Data was analysed employing principles set out by Glaser and Strauss (1967) and Gagliardi (1991). This involves scrutinising data and assigning meanings in the form of codes to key behaviours and relationships within the data. A checklist for data analysis was employed in order that the process was methodical, and that no essential elements were omitted or skimped. Chenitz and Swanson (1986) provide a six-point guide for categorisation in grounded theory research, and this provided a structure in this case.
In order to facilitate the discussion of the process of categorisation, a diagrammatic representation of the categories finally derived at the end of the process is given at this point. The categories that are underlined at the left of the page represent the abstract codings; the names appearing elsewhere on the page are examples or incidents from the data.
Categorising the ‘Difficult’ Patient
Difficult to NurseThis is quite distinct from ‘difficult’ for most contributors
Difficult by diagnosis:StrokeBack PainMunchausen’s
AlcoholicsSyndrome
Antisocial BehaviourDrunksGluesniffersChild Abusers
Breaks Social ConventionsNastyRudeBad-Mannered
Abusive
Threats to Professional AutonomyLitigatorsComplainers
Involving staff in Litigation
Record-Keepers‘Second Opinion’
ManipulatorSets Staff against Staff Winds up Others
Patient in ChargeExpects to be BossSelfish
To the Manor BornTreated Like RoyaltyNurse As Skivvy
Overlooks others
I want to be firstPerceived Trivial Requests Demanding
Bellringer
Breaks the Unwritten RulesNon-ConformingNon-Compliant Defeatist ‘Sexual Overtones’
Doesn’t Try
Knows The Score‘Hospital Bird’ Regular Attender
‘Hangs out with Staff’
AggressionScreamingShoutingViolent
Difficult’ patients or ‘Difficult to Nurse’?
One issue to emerge at this stage of data analysis was the necessity to tease out and put in place the issue of ‘Difficult to Nurse’ as opposed to ‘Difficult’. Anecdotal and professional experience of the researcher had suggested that this distinction was a possible source of confusion, therefore a specific trigger question was incorporated so the groups would explore this area. The question turned out to be superfluous in some respects, as the card-sorting exercise tended to bring this issue straight into the open. However, some staff clearly were uncertain about distinguishing between the terms.
PCMoving on to the other people who are in the pile,... looking at the patients themselves, what is it about those people, ehm, that makes you think ‘ they’re difficult’ or ‘they’re unpopular’?
2Well, Mrs. T., She’s got Alzheimer’s... She’s very difficult to nurse.
This participant appears to confuse the terms ‘difficult’ and ‘difficult to nurse’, although it has to be said that this was a minority view, and that most staff saw these concepts as quite distinct. The principles that seem to define these two views will be further explored, but seem to depend upon whether the patient consciously opts to behave in a difficult manner, in which case they were ‘difficult’. Most staff felt that a patient who had no deliberate intent to trouble staff, such as confused patients, were a nursing issue. The notion of ‘Patient Volition’ in difficulty had emerged.
Difficult by Diagnosis
Here staff cited patients suffering from Strokes, Multiple Sclerosis, Munchausen’s Syndrome, and Alcoholism. Some instances appear less clear-cut as a diagnostic label, as reference is made to other difficult behaviour, such as ‘demanding’ in the case of patients with COAD, demonstrated below;
11The characteristics that follow through with like COAD's patients do have similar characteristics; similar things that follow through with each of them...
PCSuch as?
13Well, that they are, sort of, wanting something there and then, and as they progress it becomes more and more a demanding thing.
When asked directly about considering patients as ‘difficult’ purely on the basis of their diagnosis, staff tended to be reluctant to concede that such a thing could happen.
Difficult by Virtue of Anti-Social Behaviour
Here, patients who indulge in socially (i.e. outside of hospital) unacceptable behaviour such as drunks, gluesniffers, wife-beaters and child-abusers are likely to be labelled as ‘difficult’ within hospital. This would seem to stem from the social unpopularity of these behaviours, as well as the probability of a clash with nursing staff if the behaviour continues within hospital
10I nursed a guy who was ehm,..., well I don't know what he came in for, but he was a terrible, like, gluesniffer. You know. he was like..., he just had this attitude about him, and like he kept on doing it on the ward, like I mean he was getting wrong for it off the Sister, you know there was other patients on the ward, he kept sneaking in. But he just had this attitude like ‘I'm so clever, you know, doing this’, and you know, I just couldn't stand him. I couldn't bear to be near him, he was so, whey, difficult. Just, he wouldn't do anything you said, he was just so awkward.
Some categories noted are ‘subsets’ or ‘subdivisions’ of each other, often with only subtle differences between them. An illustration of closely related categories is ‘To the Manor Born’, ‘Treated like Royalty’ and ‘The Nurse as a Skivvy’. These are essentially three very similar groups, but with the patients’ behaviour becoming increasingly less pleasant through the three categories.
8...Sometimes some of them just expect to be treated like earls, you know ‘It’s your job, that’s what you’re paid for’. (Inaudible) Even if they just say ‘please... please and thank you’ it makes a difference.
In comparison, ‘Nurse as Skivvy’ involves even less pleasant, outright rude behaviour, and links to the bad-mannered category, but contains the specific element of treating the nurse as a servant.
9She was...today I gave her her dinner. I was, no I didn’t... I come back to see if she was eating her dinner, and she was... ‘HEY!’ and I turned round and she was pointing at her dinner and she wouldn’t let us go on to the ward, I said ‘what’s the matter?’ you know. ‘Cut that’ (said very unpleasantly).
This patient also has the additional ‘difficulty weighting’ of having had a stroke. The analysis of these, and other categories, was pursued with the aim of finding a conceptual framework within which they could be placed, and which could lead to a greater understanding of what was happening here. An abstract notion of what was eventually termed ‘Patient Rules’ started to emerge from the data. Using this framework, the behavioural aspects of ‘difficulty’ all seemed to contravene an unwritten set of conditions that nurses appeared to expect patients to fulfil or adhere to as part of their stay.
’The Patient Rules’
Patients are expected to adhere to everyday social conventions whilst in hospital
Many accounts referred to patients who were rude or bad mannered to nurses. A couple of cases involving physically violent patients were included but these were unusual. However, verbal aggression appeared relatively often within the transcripts, and instances of inappropriate touching of nurses’ persons by patients were also recounted. Extreme examples of rudeness include ‘Nurse as Skivvy’ mentioned above. Some participants explicitly stated that manners and politeness were felt to be an important element of the nurse-patient relationship.
10They don't have to like behave, sort of like, you know, ‘you sit there and be quiet’, type of thing. I mean, you do expect them to be, like, polite and sort of, do realise that you do have other patients…
The issue of politeness becomes very important later in the analysis, when the relative nature of ‘difficulty’ is discussed, as well as ‘redeeming qualities’ in patients.
Patients should assist themselves in their own recovery.
This category is similar to that put forward by Parsons in 1951 as part of The Sick Role (‘Patients should want to recover’). Many participants referred to patients whom it was felt were not contributing to their own recovery. The researcher asked participants if they were convinced that this was the case, rather than were just assuming. Participants often gave illustrations to support their judgement.