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CONTINUING PROFESSIONAL DEVELOPMENT
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Stigmatised patients multiple choice questionnaire
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Promoting better care for stigmatised patients NS774 Pottle J, Marotta J (2014) Promoting better care for stigmatised patients. Nursing Standard. 29, 16-18, 50-59. Date of submission: July 25 2014; date of acceptance: October 6 2014.
Aim and intended learning outcomes
Abstract This article discusses the role of nurses and nurse leaders in the prevention and resolution of patient stigmatisation. The multiple nurse, patient and environmental factors that contribute to difficulties in nurse-patient interactions are outlined. The antecedents and consequences of patient stigmatisation are discussed and leadership strategies for counteracting and preventing patient stigmatisation are explored. The reader is encouraged to reflect on the role of patient stigmatisation in nursing practice and consider ways to promote better care of stigmatised patients.
Authors Jessica Pottle Registered nurse, Virginia Mason Hospital, Seattle, Washington, United States. Jill Marotta Clinical leader, Virginia Mason Hospital, Seattle, Washington, United States. Correspondence to: [email protected]
Keywords Conflict resolution, difficult patient, nurse-patient relationship, nursing ethics, patient satisfaction, patient stigmatisation
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The aim of this article is to present nurses and nurse leaders with strategies to prevent and resolve patient stigmatisation. It explores the antecedents and consequences of patient stigmatisation with reference to the literature. It also explores the characteristics that distinguish professional nurse-patient interactions from social interpersonal interactions. A brief review of professional nursing ethics and Orlando’s (1990) theory of the deliberative nursing process is undertaken. Consideration is given to leadership strategies to resolve nurse-patient conflict. Finally, proactive strategies to prevent difficult nurse-patient encounters are explored. After reading this article and completing the time out activities you should be able to: Analyse the interactional factors that contribute to difficulties in nurse-patient encounters. Examine patient stigmatisation and its consequences. Outline the professional and ethical mandates to prevent and counteract patient stigmatisation. Identify leadership strategies to promote patient and nurse dignity when patient stigmatisation has occurred. Describe techniques used to prevent patient stigmatisation.
Introduction In his 1963 seminal work on stigma, sociologist Erving Goffman defined it as ‘the situation of the individual who is disqualified from full social acceptance’ (Goffman 1963).
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Stigmatisation is a social phenomenon resulting from the implicit categorisation of attributes as acceptable or unacceptable. According to Goffman (1963), ‘society establishes the means of categorising persons and the complement of attributes felt to be ordinary and natural for members of each of these categories’. An individual may be found to possess an attribute that differs from the expected norm in a way that is undesirable. When this discrepancy is extreme, the individual may be ‘reduced in our minds from a whole and usual person to a tainted, discounted one’ (Goffman 1963). This discounting is stigmatisation. Goffman (1963) identified three categories of people who are at high risk of stigmatisation: Individuals with physical deformities such as missing limbs, paralysis or scars. Individuals with blemishes of character related to their lifestyle and past choices, such as a history of incarceration, attempted suicide, sexual promiscuity, mental illness or addiction. Individuals affiliated with marginalised racial, national or religious groups. Nurses have implicit expectations for how ‘normal’, ‘acceptable’ patients should behave in the acute care environment. Sociologist Talcott Parsons (1964) elucidated tacit elements of the socially expected ‘sick role’: that patients should want to get better and should listen to the expert advice of their caregivers. Patients who do not conform to the sick role do not align with social norms and are therefore at high risk of stigmatisation. The process of patient stigmatisation can be insidious. Many nurses are unintentionally complicit in stigmatising patients through the perpetuation of discrediting labels, such as difficult, malingering or non-compliant. Stigmatised patients are branded with deeply discrediting social labels that limit the ways in which nurses perceive their intentions and actions. Consequently, stigmatised patients are at risk of receiving impersonal and inadequate care (Macdonald 2003, Price 2013). For example, an individual with a history of substance misuse presenting to the emergency department complaining of pain and requesting pain relief medication may be regarded as a drug seeker and treated prejudicially, rather than holistically as an individual. At times, entire inpatient nursing units collude to fuel patient stigmatisation. Cook (2000) described a case of patient
stigmatisation in which an attitude of mutual resentment was adopted between the patient and the nursing staff of a medical-surgical unit. Nurses providing direct patient care discredited the stigmatised patient by: Rolling their eyes in reference to her. Substituting a pejorative nickname for her real name. Protesting publically when assigned to her care. Scoffing at her demands for respect and attention. Taking measures to evade being in her presence. In this scenario, nurse leaders may also be judged complicit in patient stigmatisation as a result of their conspicuous lack of action. Most nurses have observed or participated in cases of patient stigmatisation in which nursing staff opposed a particularly unpopular patient. Although a familiar phenomenon, patient stigmatisation should not be accepted as an inevitability of modern nursing practice. All nurses have a responsibility to reflect critically on their own practice and that of others when stigmatisation occurs. Moreover, nurse leaders have an essential role in the prevention, early identification and resolution of patient stigmatisation. Complete time out activity 1
Antecedents and consequences of patient stigmatisation Antecedents
As discussed, discrediting labels often precede patient stigmatisation. Nurse labelling of patients as difficult is a widely characterised phenomenon that may be viewed as a facilitator of stigmatisation (Cook 2000, Macdonald 2003, Roos 2005, Khalil 2009). Macdonald (2003) performed a concept analysis of difficult patients to characterise the multifactorial and interactional attributes of the phenomenon. She identified that difficult patients displayed behavioural characteristics that conflicted with the expected patient role, personal characteristics that conflicted with the beliefs and values of the nurse, and behaviours that nurses perceived as challenging their competence and control (Macdonald 2003). Three domains emerged from this analysis (Figure 1): Patient domain – patient behaviours and characteristics (Macdonald 2003). Nurse domain – nurse beliefs, values, competence and control (Macdonald 2003).
1 Reflect on a time when you have been complicit in the stigmatisation of a patient by using a discrediting label. What motivated your behaviour at the time? What benefits, if any, did you gain by labelling the patient? How could you have acted differently?
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CPD nursing ethics Situation domain – the expected patient role, which includes a desire to get better and a willingness to listen to the nurses’ expert recommendations (Parsons 1964, Macdonald 2003). Two patterns of interaction were also evident: Patient-nurse conflict – the patient’s values and beliefs conflict with those of the nurse. The nurse interprets the patient’s behaviour as a challenge to her competence and control. Patient-situation conflict – the patient’s behaviour clashes with the socially accepted norms of the situation. The patient does not adhere to the ‘sick patient’ role (Parsons 1964). In light of the numerous aspects of difficult patients – which are more accurately represented as the interaction of patient factors, nurse factors and situational factors – many have advocated for an approach to thinking about difficult nurse-patient encounters (Macdonald 2007, Abbott 2012, Blackall and Green 2012, Fiester 2012, Parsi 2012).
Patient factors
In her 1972 seminal study, Felicity Stockwell asked nurses to describe the patients they least enjoyed looking after. She identified several factors associated with patients who were deemed unpopular by nurses, including unpleasant personality, negative attitude, poor communication skills, foreign nationality, prolonged hospitalisation, and disfigurement, obesity, aphasia and psychiatric conditions (Stockwell 1972). Difficult patients have
subsequently been described as patients who are violent, aggressive, abusive, rude, unco-operative, argumentative, demanding, time consuming, manipulative, anxious, unreasonable or having a disease they brought on themselves through lifestyle choices (Wolf and Robinson-Smith 2007, Khalil 2009, Price 2013, Teo et al 2013). Senior nursing students in South Africa identified physical aspects and appearance, psychological aspects, attitudinal factors, social factors and knowledge level of the patient as contributing to patient designation as difficult (Roos 2005).
Nurse factors
Challenging patient behaviour is not an objective phenomenon; what one nurse perceives as difficult another may perceive as unremarkable (Farrell et al 2010). Research suggests that patient designation as difficult depends on the attributes of the healthcare practitioner. Two prospective cohort studies found that doctors with negative attitudes regarding the management of psychosocial aspects of care were more likely to experience difficult patient encounters (Jackson and Kroenke 1999, Hinchey and Jackson 2011). Similarly, Santamaria (2000) found that nurses’ personality orientation, in terms of how they approached problem solving and coped with challenges, affected their reported stress in response to interpersonally difficult patient encounters. Solution-oriented nurses experienced less stress compared with blame-oriented nurses (Santamaria 2000). Nursing factors contributing to difficult nurse-patient encounters identified by
FIGURE 1 Factors contributing to difficult nurse-patient interactions Patient factors: Values Beliefs Attitudes Behaviours Lifestyle choices Physical attributes Social status
Nurse factors:
Situation factors:
Values Beliefs Attitudes Behaviours Skills and competence
Behavioural norms Policies and procedures Available resources Time constraints
Difficult nurse-patient interactions
(Adapted from Macdonald 2003)
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Roos (2005) included skills and experience, training and attitudinal factors. For some patients, difficult behaviours reflect rational responses to mistreatment by healthcare practitioners. Mayer (2008) explained her experience of feeling compelled to challenge her healthcare providers and adopt behaviour deemed difficult: ‘Why did I become difficult? It wasn’t my first choice… I wasn’t interested in being told what to do, and expected my doctors to respect my right to make truly informed choices that were consistent with the way in which I wanted to intervene in my disease and live my life.’ For Mayer (2008), becoming a difficult patient was necessary in response to provider paternalism. Fiester (2012) argued that a difficult patient should be considered as someone who perceives being treated unfairly, disrespectfully, dismissively, condescendingly, or offensively in the medical encounter. In other words, problematic nurse behaviour should be considered as an antecedent of nurse-patient difficulty.
Situational factors
Nursing research has shed light on the situational factors that contribute to difficult nurse-patient encounters and patient stigmatisation. Situational factors identified by Roos (2005) included management of the health service, in terms of the amount of nursing time and nursing services afforded to patients and the hospital routine. Macdonald (2007) observed nurses on a family medicine nursing unit in Canada, and performed interviews with patients and nursing staff to identify the origins of difficulties in nurse-patient encounters. She identified nurse time constraints as a root cause of nurse-patient difficulties. Factors affecting nurses’ time included: needs of patients’ families, availability of supplies and equipment, nursing staff efficiency and teamwork, and changes in the modern care environment resulting in shorter hospital stays and sicker patients with increased chronic medical conditions. Macdonald (2007) also observed a feedforward iterative cycle of difficulty in which nurses who felt pressed for time resorted to controlling behaviours such as enforcing visiting hour rules, rushing patients through care activities, and generally limiting patient choice. Patients responded negatively to this controlling behaviour (Macdonald 2007). This further increased demands on nurses’ time. The result was both nurses and patients attempting to exercise
control in an action-reaction cyclical pattern of opposition (Figure 2). When it comes to difficult nurse-patient encounters, difficulty cannot be considered an intrinsic property of the patient. Rather, difficulty results from the interaction of nurse factors, patient factors and situation factors. Rejecting the paradigm of the difficult patient is paramount to preventing and resolving patient stigmatisation. Nurse leaders must work to dispel misconceptions of patients as difficult and help nurses to consider the multiple interactional factors that contribute to perceived difficulty in nurse-patient interactions.
Consequences
Patient stigmatisation has consequences for patients and nurses. Stigmatised patients receive care that does not respect their personal values, preferences and needs, and often experience prejudicial interventions. Nurses complicit in patient stigmatisation provide lower quality nursing care and do not live up to professional ethical standards of practice. Two prospective cohort studies found that patients designated as difficult by their healthcare provider were more likely to experience negative outcomes (Jackson and Kroenke 1999, Hinchey and Jackson 2011). Difficult patients were less likely to trust or be satisfied with their clinician, and were more likely to have worsening symptoms (Hinchey and Jackson 2011); they also reported less overall satisfaction with the care they received (Jackson and Kroenke 1999).
FIGURE 2 Action-reaction cycle of nurse-patient opposition
Nurse has limited time toto care care forfor the patient patient
Patient Patientattempts attemptsto control to control thenurse’s nurse’s behaviour and demands demands more more ofof the nurse’s time
Nurse attempts to control control the patient’s patient’s behaviour
Patient feels controlled and rushed byby the nurse nurse
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CPD nursing ethics
2 What are the patient, nurse and environmental factors that contribute to patient stigmatisation in the scenario provided in Box 1? As a nurse leader, how would you intervene?
Patients identified as difficult by nurses in the inpatient mental health setting reported they had ‘no real say in their care’, and described being ignored, dismissed and not believed by nurses (Breeze and Repper 1998). Additionally, patients described feeling ‘threatened or coerced into changing or restraining their behaviour’, and described nurses’ use of ultimatums (Breeze and Repper 1998). Patients also reported responding to being treated as unimportant and untrustworthy with anger and attempts to exert control. Several authors identified nurse disengagement in response to stigmatised patients. Price (2013) described this as a conservation of resources in which nurses avoid ‘taxing’ patients and focus on more ‘agreeable’ patients. The consequence of pursuing the easy wins is that nurses miss out on the opportunity for innovation and instead rely ‘on less responsive and imaginative ways of solving problems and addressing challenges’ (Price 2013). In a qualitative study of Danish community nurses, Michaelsen (2012) identified avoidance and emotional distance as a survival strategy used by nurses to cope with difficult nurse-patient encounters. Michaelsen (2012) described negative consequences of the observed physical and psychological withdrawal of nurses: ‘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.’ Nurses preserved their sense of emotional wellbeing by distancing themselves from negative nurse-patient encounters. Attributing difficulty to the patient in these situations gave nurses permission to disconnect and expend less emotional energy. Instead of engaging with
BOX 1 Difficult nurse-patient encounter Imagine you are a nurse leader who reports for work on Monday morning and overhears nurses recounting that an unpopular patient on the unit ‘choked a nurse with the telephone cord over the weekend’. Disturbed by this report of violence, you review the patient’s electronic health record to see what was documented regarding the incident. You find that the nurse on duty wrote: 2200 – Patient held up telephone cord to nurse’s neck and made gesture as if to choke her. Security called. Patient yelling and flailing limbs, spitting. Patient placed in restraints, and 1mg lorazepam administered as required. 2300 – Patient resting quietly, conciliatory. Restraints removed. You speak to the patient, who recounts: ‘I was angry that I could not get through to my dad on the phone so I held up the phone cord in exasperation. I didn’t know it looked like I was trying to choke that nurse. I’m blind; I can’t see. I just held up the cord because I was so frustrated.’
patients on a personal level, nurses focused on physical aspects of treatment. This resulted in important factors being overlooked and missed opportunities for care (Michaelsen 2012). Nursing research has also found prejudicial treatment of stigmatised patients. In a qualitative survey of South African nurses practising in public hospitals, nurses reported that ‘good patients’ regularly received preferential care, while difficult patients were frequently avoided (Khalil 2009). Whereas nurses frequently rewarded good patients with special treatment or gifts, difficult patients were ignored or received minimum interaction (Khalil 2009). The author also reported that difficult patients were treated professionally but without compassion (Khalil 2009). In addition, 94.9% of survey respondents (354 out of 373 nurses) reported having observed nursing interventions that were discriminatory or nurses refusing to provide care to a difficult patient (Khalil 2009). Again the iterative cycle of difficult patient behaviour is apparent. Stigmatised patients are often those labelled difficult as a result of their demand for more nurse time, attention and energy. When nurses react to such demands by avoiding the patient, the patient’s demands to be heard may logically increase. The result is feedforward escalation of difficulties in the nurse-patient encounter. Complete time out activity 2
Distinguishing characteristics of professional nurse-patient interactions Whereas the purpose of social interpersonal relationships is to meet the needs of both parties involved, the purpose of professional nurse-patient relationships is to meet the needs of the patient (Orlando 1990). Professional nurse-patient relationships are asymmetrical in nature. Patient needs are the focus; the personal needs of the nurse for respect, validation and harmonious interpersonal interactions are incidental. Similarly, while avoidance and distancing are understandable responses to difficult behaviour in the context of social encounters, such patterns of behaviour do not meet ethical standards of practice in the context of professional nurse-patient encounters. Orlando’s (1990) theory of the deliberative nursing process informs professional nurse responses to difficult patient behaviour. According to Orlando (1990), difficult patient verbal and non-verbal behaviour reflects unmet needs for help. Rather than be avoided or met
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with impersonal, automated interventions, difficult behaviour should be deliberately explored by the nurse. What differentiates professional nurse caring from lay caring is the deliberative process of ascertaining patient needs, intervening to meet patient needs and validating with the patient that their needs have been met. Conversely, lay caring consists of automatic nursing processes such as providing routine care, adhering to unit policies and carrying out a doctor’s orders. Professional nursing is patient-centred and individualised (Orlando 1990). Nurses have a professional obligation to respond to the concerns and preferences of individuals, and to respect the contribution that people make to their own care and wellbeing (Nursing and Midwifery Council (NMC) 2008). Nurses should promote ‘an environment in which the human rights, values, customs and spiritual beliefs of the individual, family and community are respected’ (International Council of Nurses 2012). In addition to breaching standards of professionalism, the consequences of patient stigmatisation breach the ethical principles of justice and dignity. As discussed previously, stigmatised patients are subject to prejudicial treatment and consideration as a type of person rather than as a whole person. Honouring the principle of justice requires nurses to provide equal care to all patients that is not contingent on patient attributes or behaviour (Finkelman and Kenner 2013). This means rejecting strategies of withdrawal and avoidance when caring for challenging patients, and respecting the inherent worth of all patients as whole people (NMC 2008), approaching each patient with respect and positive regard.
patients. Modelling respectful and empathetic nursing practice enables nurse leaders to influence the culture of their practice environment in a positive way and set a precedent for nurses. Two essential skill sets for nurse leaders to model in the care of stigmatised patients are open communication and patient advocacy. Modelling open communication involves approaching patients with respect, avoiding judgement-laden labels and focusing on the issue at hand (Wolf and Robinson-Smith 2007). Expert communicators move the focus of conversation away from personal accusations of fault and towards co-operative problem solving (Wolf and Robinson-Smith 2007). One strategy for enabling open communication is to name the emotion or feeling, validate the effect or emotion and align with the patient (Teo et al 2013). The nurse names the emotion she perceives in the patient – for example, ‘You seem frustrated.’ Reflection helps the patient to feel heard. The nurse validates the effect or emotion – for example, ‘You’ve been dealing with the pain in your back for a long time and the pain medications are not helping. That’s a lot for anyone to cope with.’ Validation helps the patient to feel respected and know that their concerns are regarded as legitimate. Finally the nurse aligns herself with the patient – for example, ‘I want to do everything in my power to help you feel comfortable enough to be able to sleep.’ Alignment helps the patient feel supported and develops trust (Teo et al 2013).
TABLE 1 Leadership strategies for resolving nurse-patient conflict
Leadership strategies for resolving nurse-patient conflict Reflection on professionalism and ethical principles in nursing reveals that nurse leaders have a duty to prevent and resolve patient stigmatisation. Nurse leaders are equipped with multiple tools for intervening when patient stigmatisation has occurred and patterns of conflict dominate nurse-patient interactions. These include modelling expert communication skills and patient advocacy, coaching nurses, exploring narratives and acting as a third-party mediator (Table 1).
Modelling
Nurse leaders should lead by example in promoting high quality care for stigmatised
Strategy
Rationale
Modelling respectful and empathetic nursing practice
Your expert implementation of communication skills, positive regard and patient advocacy serves as an example for nurses.
Coaching nurses on open communication skills and patient advocacy
Nurses experiencing stressful interpersonal encounters may require just-in-time encouragement and direction to sustain high quality patient care.
Exploring narratives
By exploring patients’ personal stories and sources of motivation, and sharing these stories with nurses, you can help nurses to see patients holistically and regard patients with greater empathy.
Third-party conflict resolution
Nurses embedded in conflict with patients may not have the ability to negotiate a resolution. As a neutral third party, you can help to refocus interactions on problem solving instead of blaming and shaming.
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CPD nursing ethics Aligning with the patient also lays the foundation for advocacy. Nurse leaders model advocacy by striving to protect the health, safety, and rights of the patient (International Council of Nurses 2012). In the context of stigmatised patients, advocacy may involve adopting a position counter to the consensus of nursing staff. Consider a patient who has been labelled non-compliant for refusing to follow a diabetic diet, while requesting frequent blood glucose monitoring and sliding scale insulin administration. The nurse feels strongly that the patient should be compelled to restrict dietary added sugar intake. The patient verbalises understanding of the association between oral intake and blood sugar levels, but is insistent on having the freedom to consume a regular diet. The nurse leader may advocate for the patient’s right to autonomy in directing his or her care.
Coaching nurses
3 A patient who has been hospitalised for 120 days, and with a history of multiple adversarial interactions with nurses, has a birthday coming up. She wants to have a party, and is requesting that a room is reserved for her and her guests to use. It is common practice at the hospital for rooms to be reserved for patients and their families, especially in cases of extended length of hospital stay. Nurses feel strongly that accommodation should not be made for this patient since they see it as a reward for her negative behaviour. As nurse leader, what would you do? How might stigmatisation of the patient be affecting the nurses’ reactions to her request?
Nurse leaders can promote better care for stigmatised patients by coaching nurses on strategies to improve interpersonal interactions (Davis et al 2012). This includes coaching regarding open communication skills and patient advocacy. Additionally, nurse leaders can provide just-in-time coaching to support nurses who feel adverse emotions in response to challenging nurse-patient encounters. This includes helping the nurse to reframe negative patient behaviour as a response to multiple factors rather than a personal attack on the nurse or a negative reflection of the nurses’ professional competency. Coaching also includes helping nurses to reflect on their professional values and validating the importance of ethical nursing care even during a perceived lack of patient appreciation.
Exploring narratives
Exploring patient and nurse narratives can increase empathy and understanding. Knowing the patient’s situation enables the nurse to see the patient as a whole person, rather than an aggregate of decontextualised negative behaviour. Price (2013) wrote: ‘Exploring narratives with patients arguably helps to make them interesting. As individuals explain how past life experiences have shaped their current interpretation of a problem now, this serves to mark out their individual way of responding and to lend greater integrity to their efforts.’ Patients and nurses construct personal stories about the meaning of their circumstances (Price 2013). Exploring narratives is a
central practice of narrative ethics, which involves the exploration of personal stories, and clarification of the values, beliefs and moral choices that inform such personal stories (Davis et al 2012). The aim of narrative ethics is to understand what motivates and sustains the behaviour of individuals and the meanings they have ascribed to the actions of others (Davis et al 2012). Nurse leaders explore narratives to highlight areas of misunderstanding and identify root causes of conflict in nurse-patient encounters (Davis et al 2012). Nursing research has shown that the meaning nurses ascribe to patient behaviour affects the ways in which they respond to patients. Nurses responded with greater patience and calmness when they could empathise with patients who demonstrated violent behaviour (Luck et al 2008).
Conflict resolution
Serving as a third-party mediator of conflict is one way for nurse leaders to resolve difficult nurse-patient interactions. Often, nurses embroiled in difficult nurse-patient encounters are dealing with negative feelings of anger, frustration, anxiety or guilt (Fiester 2012). As a stakeholder in conflict, they might not have the perspective or patience to also be able to mediate that conflict (Fiester 2012). Nurse leaders can step in with objectivity and emotional detachment to create a third story, which is a version of events on which both stakeholders can agree (Fiester 2012). Mediation enables the nurse leader to disrupt a pattern of blame and shame, and redirect the efforts of the nurse and the patient towards co-operative problem solving (Abbott 2012). Four mediation techniques for nurse leaders to employ are: listening for understanding, reframing, evaluating the definition of the problem, and creating clear agreements (Gerardi 2004). First, the nurse leader listens to the nurse and patient with the aim of learning what emotions, values and needs are contributing to the conflict. When blaming statements arise, the nurse leader helps to reframe the problem by acknowledging the emotion behind accusations of culpability, removing inflammatory language, restating the problem or issue, and seeking clarification or validation from the nurse or patient (Gerardi 2004). Next, the nurse leader characterises the problem in a manner that both the nurse and the patient can accept. Finally, the nurse leader helps to shape agreement between the nurse and patient. Complete time out activity 3
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Strategies for preventing difficult nurse-patient encounters Nurse leaders can take various approaches to prevent difficult nurse-patient encounters. Several effective strategies include training nurses in how to negotiate difficult encounters, reducing workday time constraints to allow time for nurses to know their patients as individuals, and identifying patients at risk of exhibiting negative behaviour (Table 2).
Training nurses
Prevention of difficult nurse-patient encounters begins with fundamental elements of respectful interactions. This includes approaching patients politely with positive regard, listening actively, responding objectively, sharing power, avoiding judgement and refraining from labelling patients when communicating with other professional caregivers (Wolf and Robinson-Smith 2007). Training nurses in how to negotiate difficult nurse-patient encounters has been proven to boost their confidence to enhance patient care (Brunero and Lamont 2010). Nurses who completed a scenario-based electronic-learning
module self-reported increased confidence, knowledge and skill combined with decreased interpersonal stress in managing difficult interpersonal interactions (Brunero and Lamont 2010). The self-other-setting (SOS) conceptual model has been proposed for developing curricula to train nurses in high quality nurse-patient interactions (Farrell et al 2010) (Table 3). The SOS model involves helping nurses to consider the multiple domains that contribute to difficult nurse-patient encounters and meet learning objectives at two levels of critical thinking: understanding and application (Farrell et al 2010). First, the nurse is challenged to reflect on how his or her own attributes and behaviours contribute to conflict and cause him or her to respond negatively to the patient. Next, the nurse is asked to consider attributes of the patient that contribute to difficulties. Finally, the nurse is tasked with understanding attributes of the healthcare setting that promote difficulties, including the nature of the physical environment, time constraints and social expectations for patient compliance.
TABLE 2 Leadership strategies for preventing difficult nurse-patient interactions Strategy
Rationale
Training nurses in high quality nurse-patient interactions
Using scenario-based learning to train nurses in how to negotiate challenging patient encounters improves the skill level and confidence of nurses.
Reducing workday time constraints of nurses
Ensuring that nurses have sufficient time to get to know patient preferences and values and offer individualised care to patients reduces conflict triggers.
Identifying patients at risk for stigmatisation via formal screening tools and/or nurse leader patient rounds
Screening patients for early warning signs of stigmatisation allows for targeted prevention and swift intervention.
TABLE 3 The self-other-setting conceptual model for training nurses Domains Self
Other
Setting
Understanding
Build understanding of how the nurse’s values, emotions and communication skills contribute to difficult nurse-patient encounters.
Build understanding of how attributes of the patient and the patient’s patterns of responding to illness contribute to difficult nurse-patient encounters.
Build understanding of how cultural and physical attributes of the care environment contribute to difficult nurse-patient encounters.
Application
Promote application of professional values, positive regard and expert communication skills.
Promote application of advocacy and respect for the patient’s perspective.
Promote application of environmental management skills.
Levels
(Adapted from Farrell et al 2010)
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CPD nursing ethics
4 Consider how you would apply the self-other-setting conceptual model to the development of an education project in your practice area. Write one learning objective for each learning domain.
Implementation of the SOS model is best achieved with scenario-based learning which is delivered via mixed modalities (Farrell and Salmon 2009). Scenario-based learning includes application exercises and opportunities for learners to try out techniques in practice. The use of structured reporting forms to monitor difficulties and consequences of learning application combined with supported resources assist scenario-based learning. For example, learners could be asked to keep journals or complete process recordings of their implementation of learning objectives in practice. Learners and instructors could review logs of applied learning jointly and discuss how to improve interactions in the future. Mixed modalities appeal to diverse learner needs and may include both internet-based and face-to-face learning (Farrell and Salmon 2009). Complete time out activity 4
Reducing workday time constraints
Root causes of nurse-patient difficulty identified through qualitative study include not knowing the patient and workday time constraints (Macdonald 2007). Ensuring
that staffing levels allow nurses adequate time to interact directly with patients is one way in which nurse leaders can strive to prevent patient stigmatisation. In addition, nurse leaders can develop formal assessment tools for nurses to learn and apply patient preferences and values. This would enhance nurse understanding of patients and circumvent conflict.
Identifying at-risk patients
Identification of patients at risk of exhibiting negative behaviour during their hospital stay is another strategy for preventing difficult nurse-patient encounters. Baker et al (2006) described an assessment tool for recognising red flags, such as extended length of hospital stay, complex multisystem disease process, nurse requests not to care for a patient and conflict regarding plan of care. Patients identified as high risk for negative behaviours received targeted interventions to promote interdisciplinary team-patient collaboration, shared decision making and problem solving. The process of screening and early intervention resulted in a 71% decrease in patient service complaints (Baker et al 2006).
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Goffman E (1963) Stigma: Notes on the Management of Spoiled Identity. Penguin Books, London. Hinchey SA, Jackson JL (2011) A cohort study assessing difficult patient encounters in a walk-in primary care clinic, predictors and outcomes. Journal of General Internal Medicine. 26, 6, 588-594.
Finkelman A, Kenner C (2013) Professional Nursing Concepts. Second edition. Jones & Bartlett Learning, Burlington MA.
International Council of Nurses (2012) The ICN Code of Ethics for Nurses. www.icn.ch/images/ stories/documents/about/ icncode_english.pdf (Last accessed: November 10 2014.)
Gerardi D (2004) Using mediation techniques to manage conflict and create healthy work environments. American Association of Critical Care Nurses Clinical Issues. 15, 2, 182-195.
Jackson JL, Kroenke K (1999) Difficult patient encounters in the ambulatory clinic: clinical predictors and outcomes. Archives of Internal Medicine. 159, 10, 1069-1075.
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Patient rounds led by the nurse leader are an effective strategy for promoting positive nurse-patient interactions and identifying patients at risk of experiencing difficult nurse-patient encounters. The aim of nurse leader patient rounds is to demonstrate to patients the hospital’s commitment to providing high quality care, enable information sharing, establish expectations for the hospital experience and to ensure that patient expectations are being met (Studer Group 2008). Nurse leader rounding at pivotal times of the hospital experience – for example, admission, transfer to a new unit or immediately before hospital discharge – improves patient satisfaction and safety (Baker 2010). Complete time out activity 5
Conclusion Stigmatisation is a phenomenon of reducing, discrediting and discounting. Stigmatised patients are regarded by nurses in terms of their perceived deviance from social norms, rather than as holistic individuals. Consequently, they experience prejudice and are at risk of receiving impersonal
Khalil D (2009) Nurses’ attitude towards ‘difficult’ and ‘good’ patients in eight public hospitals. International Journal of Nursing Practice. 15, 5, 437-443. Luck L, Jackson D, Usher K (2008) Innocent or culpable? Meanings that emergency department nurses ascribe to individual acts of violence. Journal of Clinical Nursing. 17, 8, 1071-1078. Macdonald M (2003) Seeing the cage: stigma and its potential to inform the concept of the difficult patient. Clinical Nurse Specialist. 17, 6, 305-310. Macdonald M (2007) Origins of difficulty in the nurse-patient encounter. Nursing Ethics. 14, 4, 510-521.
and inadequate care. This can create a feedforward action-reaction cycle of nurse-patient opposition. Nurse labelling of patients as difficult is a significant antecedent to patient stigmatisation. Appreciation of the nurse, patient and situation factors that contribute to difficulties in nurse-patient encounters is the crucial first step in preventing patient stigmatisation. All nurses have an ethical and professional obligation to treat each patient as an individual with inherent dignity. Similarly, all nurses have a responsibility to advocate for patients and intervene when stigmatisation occurs. Nurse leaders, in particular, have an important role in addressing patient stigmatisation with proactive prevention measures and timely interventions. Several leadership strategies were considered, including modelling, coaching, exploring narratives, conflict resolution, training nurses, reducing workday time constraints for nurses and identifying patients at increased risk of stigmatisation. Nurse leaders can promote high quality nurse-patient interactions using the strategies discussed in this article NS Complete time out activity 6
Mayer ML (2008) On being a ‘difficult’ patient. Health Affairs. 27, 5, 1416-1421.
relationship: can ethics consultants really help? American Journal of Bioethics. 12, 5, 1.
Michaelsen JJ (2012) Emotional distance to so-called difficult patients. Scandinavian Journal of Caring Sciences. 26, 1, 90-97.
Parsons T (1964) Social Structure and Personality. Free Press, New York NY.
Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. NMC, London. Orlando IJ (1990) The Dynamic Nurse-Patient Relationship. Function, Process and Principles. National League for Nursing, New York NY. Parsi K (2012) Shifting from the difficult patient to the difficult
Price B (2013) Countering the stereotype of the unpopular patient. Nursing Older People. 25, 6, 27-34. Roos JH (2005) Nurses’ perceptions of difficult patients. Health SA Gesondheid. 10, 1, 52-61. Santamaria N (2000) The relationship between nurses’ personality and stress levels reported when caring for interpersonally difficult patients. Australian Journal of Advanced Nursing. 18, 2, 20-26.
5 Critically reflect on your own practice. How do you prevent difficulties in nurse-patient encounters? List two ways in which you could improve. 6 Now that you have completed the article, you might like to write a reflective account. Guidelines to help you are on page 62.
Stockwell F (1972) The Unpopular Patient. Royal College of Nursing and National Council of Nurses of the United Kingdom, London. Studer Group (2008) Rounding for Outcomes. Rounding on Patients Guidelines. tinyurl. com/pb6d4t2 (Last accessed: November 10 2014.) Teo A, Du YB, Escobar JI (2013) How can we better manage difficult patient encounters? Journal of Family Practice. 62, 8, 414-421. Wolf ZR, Robinson-Smith G (2007) Strategies used by clinical nurse specialists in ‘difficult’ clinician-patient situations. Clinical Nurse Specialist. 21, 2, 74-84.
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CONTINUING PROFESSIONAL DEVELOPMENT
Page 60
Stigmatised patients multiple choice questionnaire
Page 61
Read Helen Fowles’ reflective account on nursing research
Page 62
Guidelines on how to write a reflective account
Promoting better care for stigmatised patients NS774 Pottle J, Marotta J (2014) Promoting better care for stigmatised patients. Nursing Standard. 29, 16-18, 50-59. Date of submission: July 25 2014; date of acceptance: October 6 2014.
Aim and intended learning outcomes
Abstract This article discusses the role of nurses and nurse leaders in the prevention and resolution of patient stigmatisation. The multiple nurse, patient and environmental factors that contribute to difficulties in nurse-patient interactions are outlined. The antecedents and consequences of patient stigmatisation are discussed and leadership strategies for counteracting and preventing patient stigmatisation are explored. The reader is encouraged to reflect on the role of patient stigmatisation in nursing practice and consider ways to promote better care of stigmatised patients.
Authors Jessica Pottle Registered nurse, Virginia Mason Hospital, Seattle, Washington, United States. Jill Marotta Clinical leader, Virginia Mason Hospital, Seattle, Washington, United States. Correspondence to: [email protected]
Keywords Conflict resolution, difficult patient, nurse-patient relationship, nursing ethics, patient satisfaction, patient stigmatisation
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software
Online For related articles visit the archive and search using the keywords above. To write a CPD article: please email [email protected] Guidelines on writing for publication are available at: rcnpublishing.com/r/authorguidelines
The aim of this article is to present nurses and nurse leaders with strategies to prevent and resolve patient stigmatisation. It explores the antecedents and consequences of patient stigmatisation with reference to the literature. It also explores the characteristics that distinguish professional nurse-patient interactions from social interpersonal interactions. A brief review of professional nursing ethics and Orlando’s (1990) theory of the deliberative nursing process is undertaken. Consideration is given to leadership strategies to resolve nurse-patient conflict. Finally, proactive strategies to prevent difficult nurse-patient encounters are explored. After reading this article and completing the time out activities you should be able to: Analyse the interactional factors that contribute to difficulties in nurse-patient encounters. Examine patient stigmatisation and its consequences. Outline the professional and ethical mandates to prevent and counteract patient stigmatisation. Identify leadership strategies to promote patient and nurse dignity when patient stigmatisation has occurred. Describe techniques used to prevent patient stigmatisation.
Introduction In his 1963 seminal work on stigma, sociologist Erving Goffman defined it as ‘the situation of the individual who is disqualified from full social acceptance’ (Goffman 1963).
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Stigmatisation is a social phenomenon resulting from the implicit categorisation of attributes as acceptable or unacceptable. According to Goffman (1963), ‘society establishes the means of categorising persons and the complement of attributes felt to be ordinary and natural for members of each of these categories’. An individual may be found to possess an attribute that differs from the expected norm in a way that is undesirable. When this discrepancy is extreme, the individual may be ‘reduced in our minds from a whole and usual person to a tainted, discounted one’ (Goffman 1963). This discounting is stigmatisation. Goffman (1963) identified three categories of people who are at high risk of stigmatisation: Individuals with physical deformities such as missing limbs, paralysis or scars. Individuals with blemishes of character related to their lifestyle and past choices, such as a history of incarceration, attempted suicide, sexual promiscuity, mental illness or addiction. Individuals affiliated with marginalised racial, national or religious groups. Nurses have implicit expectations for how ‘normal’, ‘acceptable’ patients should behave in the acute care environment. Sociologist Talcott Parsons (1964) elucidated tacit elements of the socially expected ‘sick role’: that patients should want to get better and should listen to the expert advice of their caregivers. Patients who do not conform to the sick role do not align with social norms and are therefore at high risk of stigmatisation. The process of patient stigmatisation can be insidious. Many nurses are unintentionally complicit in stigmatising patients through the perpetuation of discrediting labels, such as difficult, malingering or non-compliant. Stigmatised patients are branded with deeply discrediting social labels that limit the ways in which nurses perceive their intentions and actions. Consequently, stigmatised patients are at risk of receiving impersonal and inadequate care (Macdonald 2003, Price 2013). For example, an individual with a history of substance misuse presenting to the emergency department complaining of pain and requesting pain relief medication may be regarded as a drug seeker and treated prejudicially, rather than holistically as an individual. At times, entire inpatient nursing units collude to fuel patient stigmatisation. Cook (2000) described a case of patient
stigmatisation in which an attitude of mutual resentment was adopted between the patient and the nursing staff of a medical-surgical unit. Nurses providing direct patient care discredited the stigmatised patient by: Rolling their eyes in reference to her. Substituting a pejorative nickname for her real name. Protesting publically when assigned to her care. Scoffing at her demands for respect and attention. Taking measures to evade being in her presence. In this scenario, nurse leaders may also be judged complicit in patient stigmatisation as a result of their conspicuous lack of action. Most nurses have observed or participated in cases of patient stigmatisation in which nursing staff opposed a particularly unpopular patient. Although a familiar phenomenon, patient stigmatisation should not be accepted as an inevitability of modern nursing practice. All nurses have a responsibility to reflect critically on their own practice and that of others when stigmatisation occurs. Moreover, nurse leaders have an essential role in the prevention, early identification and resolution of patient stigmatisation. Complete time out activity 1
Antecedents and consequences of patient stigmatisation Antecedents
As discussed, discrediting labels often precede patient stigmatisation. Nurse labelling of patients as difficult is a widely characterised phenomenon that may be viewed as a facilitator of stigmatisation (Cook 2000, Macdonald 2003, Roos 2005, Khalil 2009). Macdonald (2003) performed a concept analysis of difficult patients to characterise the multifactorial and interactional attributes of the phenomenon. She identified that difficult patients displayed behavioural characteristics that conflicted with the expected patient role, personal characteristics that conflicted with the beliefs and values of the nurse, and behaviours that nurses perceived as challenging their competence and control (Macdonald 2003). Three domains emerged from this analysis (Figure 1): Patient domain – patient behaviours and characteristics (Macdonald 2003). Nurse domain – nurse beliefs, values, competence and control (Macdonald 2003).
1 Reflect on a time when you have been complicit in the stigmatisation of a patient by using a discrediting label. What motivated your behaviour at the time? What benefits, if any, did you gain by labelling the patient? How could you have acted differently?
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CPD nursing ethics Situation domain – the expected patient role, which includes a desire to get better and a willingness to listen to the nurses’ expert recommendations (Parsons 1964, Macdonald 2003). Two patterns of interaction were also evident: Patient-nurse conflict – the patient’s values and beliefs conflict with those of the nurse. The nurse interprets the patient’s behaviour as a challenge to her competence and control. Patient-situation conflict – the patient’s behaviour clashes with the socially accepted norms of the situation. The patient does not adhere to the ‘sick patient’ role (Parsons 1964). In light of the numerous aspects of difficult patients – which are more accurately represented as the interaction of patient factors, nurse factors and situational factors – many have advocated for an approach to thinking about difficult nurse-patient encounters (Macdonald 2007, Abbott 2012, Blackall and Green 2012, Fiester 2012, Parsi 2012).
Patient factors
In her 1972 seminal study, Felicity Stockwell asked nurses to describe the patients they least enjoyed looking after. She identified several factors associated with patients who were deemed unpopular by nurses, including unpleasant personality, negative attitude, poor communication skills, foreign nationality, prolonged hospitalisation, and disfigurement, obesity, aphasia and psychiatric conditions (Stockwell 1972). Difficult patients have
subsequently been described as patients who are violent, aggressive, abusive, rude, unco-operative, argumentative, demanding, time consuming, manipulative, anxious, unreasonable or having a disease they brought on themselves through lifestyle choices (Wolf and Robinson-Smith 2007, Khalil 2009, Price 2013, Teo et al 2013). Senior nursing students in South Africa identified physical aspects and appearance, psychological aspects, attitudinal factors, social factors and knowledge level of the patient as contributing to patient designation as difficult (Roos 2005).
Nurse factors
Challenging patient behaviour is not an objective phenomenon; what one nurse perceives as difficult another may perceive as unremarkable (Farrell et al 2010). Research suggests that patient designation as difficult depends on the attributes of the healthcare practitioner. Two prospective cohort studies found that doctors with negative attitudes regarding the management of psychosocial aspects of care were more likely to experience difficult patient encounters (Jackson and Kroenke 1999, Hinchey and Jackson 2011). Similarly, Santamaria (2000) found that nurses’ personality orientation, in terms of how they approached problem solving and coped with challenges, affected their reported stress in response to interpersonally difficult patient encounters. Solution-oriented nurses experienced less stress compared with blame-oriented nurses (Santamaria 2000). Nursing factors contributing to difficult nurse-patient encounters identified by
FIGURE 1 Factors contributing to difficult nurse-patient interactions Patient factors: Values Beliefs Attitudes Behaviours Lifestyle choices Physical attributes Social status
Nurse factors:
Situation factors:
Values Beliefs Attitudes Behaviours Skills and competence
Behavioural norms Policies and procedures Available resources Time constraints
Difficult nurse-patient interactions
(Adapted from Macdonald 2003)
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Roos (2005) included skills and experience, training and attitudinal factors. For some patients, difficult behaviours reflect rational responses to mistreatment by healthcare practitioners. Mayer (2008) explained her experience of feeling compelled to challenge her healthcare providers and adopt behaviour deemed difficult: ‘Why did I become difficult? It wasn’t my first choice… I wasn’t interested in being told what to do, and expected my doctors to respect my right to make truly informed choices that were consistent with the way in which I wanted to intervene in my disease and live my life.’ For Mayer (2008), becoming a difficult patient was necessary in response to provider paternalism. Fiester (2012) argued that a difficult patient should be considered as someone who perceives being treated unfairly, disrespectfully, dismissively, condescendingly, or offensively in the medical encounter. In other words, problematic nurse behaviour should be considered as an antecedent of nurse-patient difficulty.
Situational factors
Nursing research has shed light on the situational factors that contribute to difficult nurse-patient encounters and patient stigmatisation. Situational factors identified by Roos (2005) included management of the health service, in terms of the amount of nursing time and nursing services afforded to patients and the hospital routine. Macdonald (2007) observed nurses on a family medicine nursing unit in Canada, and performed interviews with patients and nursing staff to identify the origins of difficulties in nurse-patient encounters. She identified nurse time constraints as a root cause of nurse-patient difficulties. Factors affecting nurses’ time included: needs of patients’ families, availability of supplies and equipment, nursing staff efficiency and teamwork, and changes in the modern care environment resulting in shorter hospital stays and sicker patients with increased chronic medical conditions. Macdonald (2007) also observed a feedforward iterative cycle of difficulty in which nurses who felt pressed for time resorted to controlling behaviours such as enforcing visiting hour rules, rushing patients through care activities, and generally limiting patient choice. Patients responded negatively to this controlling behaviour (Macdonald 2007). This further increased demands on nurses’ time. The result was both nurses and patients attempting to exercise
control in an action-reaction cyclical pattern of opposition (Figure 2). When it comes to difficult nurse-patient encounters, difficulty cannot be considered an intrinsic property of the patient. Rather, difficulty results from the interaction of nurse factors, patient factors and situation factors. Rejecting the paradigm of the difficult patient is paramount to preventing and resolving patient stigmatisation. Nurse leaders must work to dispel misconceptions of patients as difficult and help nurses to consider the multiple interactional factors that contribute to perceived difficulty in nurse-patient interactions.
Consequences
Patient stigmatisation has consequences for patients and nurses. Stigmatised patients receive care that does not respect their personal values, preferences and needs, and often experience prejudicial interventions. Nurses complicit in patient stigmatisation provide lower quality nursing care and do not live up to professional ethical standards of practice. Two prospective cohort studies found that patients designated as difficult by their healthcare provider were more likely to experience negative outcomes (Jackson and Kroenke 1999, Hinchey and Jackson 2011). Difficult patients were less likely to trust or be satisfied with their clinician, and were more likely to have worsening symptoms (Hinchey and Jackson 2011); they also reported less overall satisfaction with the care they received (Jackson and Kroenke 1999).
FIGURE 2 Action-reaction cycle of nurse-patient opposition
Nurse has limited time toto care care forfor the patient patient
Patient Patientattempts attemptsto control to control thenurse’s nurse’s behaviour and demands demands more more ofof the nurse’s time
Nurse attempts to control control the patient’s patient’s behaviour
Patient feels controlled and rushed byby the nurse nurse
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CPD nursing ethics
2 What are the patient, nurse and environmental factors that contribute to patient stigmatisation in the scenario provided in Box 1? As a nurse leader, how would you intervene?
Patients identified as difficult by nurses in the inpatient mental health setting reported they had ‘no real say in their care’, and described being ignored, dismissed and not believed by nurses (Breeze and Repper 1998). Additionally, patients described feeling ‘threatened or coerced into changing or restraining their behaviour’, and described nurses’ use of ultimatums (Breeze and Repper 1998). Patients also reported responding to being treated as unimportant and untrustworthy with anger and attempts to exert control. Several authors identified nurse disengagement in response to stigmatised patients. Price (2013) described this as a conservation of resources in which nurses avoid ‘taxing’ patients and focus on more ‘agreeable’ patients. The consequence of pursuing the easy wins is that nurses miss out on the opportunity for innovation and instead rely ‘on less responsive and imaginative ways of solving problems and addressing challenges’ (Price 2013). In a qualitative study of Danish community nurses, Michaelsen (2012) identified avoidance and emotional distance as a survival strategy used by nurses to cope with difficult nurse-patient encounters. Michaelsen (2012) described negative consequences of the observed physical and psychological withdrawal of nurses: ‘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.’ Nurses preserved their sense of emotional wellbeing by distancing themselves from negative nurse-patient encounters. Attributing difficulty to the patient in these situations gave nurses permission to disconnect and expend less emotional energy. Instead of engaging with
BOX 1 Difficult nurse-patient encounter Imagine you are a nurse leader who reports for work on Monday morning and overhears nurses recounting that an unpopular patient on the unit ‘choked a nurse with the telephone cord over the weekend’. Disturbed by this report of violence, you review the patient’s electronic health record to see what was documented regarding the incident. You find that the nurse on duty wrote: 2200 – Patient held up telephone cord to nurse’s neck and made gesture as if to choke her. Security called. Patient yelling and flailing limbs, spitting. Patient placed in restraints, and 1mg lorazepam administered as required. 2300 – Patient resting quietly, conciliatory. Restraints removed. You speak to the patient, who recounts: ‘I was angry that I could not get through to my dad on the phone so I held up the phone cord in exasperation. I didn’t know it looked like I was trying to choke that nurse. I’m blind; I can’t see. I just held up the cord because I was so frustrated.’
patients on a personal level, nurses focused on physical aspects of treatment. This resulted in important factors being overlooked and missed opportunities for care (Michaelsen 2012). Nursing research has also found prejudicial treatment of stigmatised patients. In a qualitative survey of South African nurses practising in public hospitals, nurses reported that ‘good patients’ regularly received preferential care, while difficult patients were frequently avoided (Khalil 2009). Whereas nurses frequently rewarded good patients with special treatment or gifts, difficult patients were ignored or received minimum interaction (Khalil 2009). The author also reported that difficult patients were treated professionally but without compassion (Khalil 2009). In addition, 94.9% of survey respondents (354 out of 373 nurses) reported having observed nursing interventions that were discriminatory or nurses refusing to provide care to a difficult patient (Khalil 2009). Again the iterative cycle of difficult patient behaviour is apparent. Stigmatised patients are often those labelled difficult as a result of their demand for more nurse time, attention and energy. When nurses react to such demands by avoiding the patient, the patient’s demands to be heard may logically increase. The result is feedforward escalation of difficulties in the nurse-patient encounter. Complete time out activity 2
Distinguishing characteristics of professional nurse-patient interactions Whereas the purpose of social interpersonal relationships is to meet the needs of both parties involved, the purpose of professional nurse-patient relationships is to meet the needs of the patient (Orlando 1990). Professional nurse-patient relationships are asymmetrical in nature. Patient needs are the focus; the personal needs of the nurse for respect, validation and harmonious interpersonal interactions are incidental. Similarly, while avoidance and distancing are understandable responses to difficult behaviour in the context of social encounters, such patterns of behaviour do not meet ethical standards of practice in the context of professional nurse-patient encounters. Orlando’s (1990) theory of the deliberative nursing process informs professional nurse responses to difficult patient behaviour. According to Orlando (1990), difficult patient verbal and non-verbal behaviour reflects unmet needs for help. Rather than be avoided or met
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with impersonal, automated interventions, difficult behaviour should be deliberately explored by the nurse. What differentiates professional nurse caring from lay caring is the deliberative process of ascertaining patient needs, intervening to meet patient needs and validating with the patient that their needs have been met. Conversely, lay caring consists of automatic nursing processes such as providing routine care, adhering to unit policies and carrying out a doctor’s orders. Professional nursing is patient-centred and individualised (Orlando 1990). Nurses have a professional obligation to respond to the concerns and preferences of individuals, and to respect the contribution that people make to their own care and wellbeing (Nursing and Midwifery Council (NMC) 2008). Nurses should promote ‘an environment in which the human rights, values, customs and spiritual beliefs of the individual, family and community are respected’ (International Council of Nurses 2012). In addition to breaching standards of professionalism, the consequences of patient stigmatisation breach the ethical principles of justice and dignity. As discussed previously, stigmatised patients are subject to prejudicial treatment and consideration as a type of person rather than as a whole person. Honouring the principle of justice requires nurses to provide equal care to all patients that is not contingent on patient attributes or behaviour (Finkelman and Kenner 2013). This means rejecting strategies of withdrawal and avoidance when caring for challenging patients, and respecting the inherent worth of all patients as whole people (NMC 2008), approaching each patient with respect and positive regard.
patients. Modelling respectful and empathetic nursing practice enables nurse leaders to influence the culture of their practice environment in a positive way and set a precedent for nurses. Two essential skill sets for nurse leaders to model in the care of stigmatised patients are open communication and patient advocacy. Modelling open communication involves approaching patients with respect, avoiding judgement-laden labels and focusing on the issue at hand (Wolf and Robinson-Smith 2007). Expert communicators move the focus of conversation away from personal accusations of fault and towards co-operative problem solving (Wolf and Robinson-Smith 2007). One strategy for enabling open communication is to name the emotion or feeling, validate the effect or emotion and align with the patient (Teo et al 2013). The nurse names the emotion she perceives in the patient – for example, ‘You seem frustrated.’ Reflection helps the patient to feel heard. The nurse validates the effect or emotion – for example, ‘You’ve been dealing with the pain in your back for a long time and the pain medications are not helping. That’s a lot for anyone to cope with.’ Validation helps the patient to feel respected and know that their concerns are regarded as legitimate. Finally the nurse aligns herself with the patient – for example, ‘I want to do everything in my power to help you feel comfortable enough to be able to sleep.’ Alignment helps the patient feel supported and develops trust (Teo et al 2013).
TABLE 1 Leadership strategies for resolving nurse-patient conflict
Leadership strategies for resolving nurse-patient conflict Reflection on professionalism and ethical principles in nursing reveals that nurse leaders have a duty to prevent and resolve patient stigmatisation. Nurse leaders are equipped with multiple tools for intervening when patient stigmatisation has occurred and patterns of conflict dominate nurse-patient interactions. These include modelling expert communication skills and patient advocacy, coaching nurses, exploring narratives and acting as a third-party mediator (Table 1).
Modelling
Nurse leaders should lead by example in promoting high quality care for stigmatised
Strategy
Rationale
Modelling respectful and empathetic nursing practice
Your expert implementation of communication skills, positive regard and patient advocacy serves as an example for nurses.
Coaching nurses on open communication skills and patient advocacy
Nurses experiencing stressful interpersonal encounters may require just-in-time encouragement and direction to sustain high quality patient care.
Exploring narratives
By exploring patients’ personal stories and sources of motivation, and sharing these stories with nurses, you can help nurses to see patients holistically and regard patients with greater empathy.
Third-party conflict resolution
Nurses embedded in conflict with patients may not have the ability to negotiate a resolution. As a neutral third party, you can help to refocus interactions on problem solving instead of blaming and shaming.
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CPD nursing ethics Aligning with the patient also lays the foundation for advocacy. Nurse leaders model advocacy by striving to protect the health, safety, and rights of the patient (International Council of Nurses 2012). In the context of stigmatised patients, advocacy may involve adopting a position counter to the consensus of nursing staff. Consider a patient who has been labelled non-compliant for refusing to follow a diabetic diet, while requesting frequent blood glucose monitoring and sliding scale insulin administration. The nurse feels strongly that the patient should be compelled to restrict dietary added sugar intake. The patient verbalises understanding of the association between oral intake and blood sugar levels, but is insistent on having the freedom to consume a regular diet. The nurse leader may advocate for the patient’s right to autonomy in directing his or her care.
Coaching nurses
3 A patient who has been hospitalised for 120 days, and with a history of multiple adversarial interactions with nurses, has a birthday coming up. She wants to have a party, and is requesting that a room is reserved for her and her guests to use. It is common practice at the hospital for rooms to be reserved for patients and their families, especially in cases of extended length of hospital stay. Nurses feel strongly that accommodation should not be made for this patient since they see it as a reward for her negative behaviour. As nurse leader, what would you do? How might stigmatisation of the patient be affecting the nurses’ reactions to her request?
Nurse leaders can promote better care for stigmatised patients by coaching nurses on strategies to improve interpersonal interactions (Davis et al 2012). This includes coaching regarding open communication skills and patient advocacy. Additionally, nurse leaders can provide just-in-time coaching to support nurses who feel adverse emotions in response to challenging nurse-patient encounters. This includes helping the nurse to reframe negative patient behaviour as a response to multiple factors rather than a personal attack on the nurse or a negative reflection of the nurses’ professional competency. Coaching also includes helping nurses to reflect on their professional values and validating the importance of ethical nursing care even during a perceived lack of patient appreciation.
Exploring narratives
Exploring patient and nurse narratives can increase empathy and understanding. Knowing the patient’s situation enables the nurse to see the patient as a whole person, rather than an aggregate of decontextualised negative behaviour. Price (2013) wrote: ‘Exploring narratives with patients arguably helps to make them interesting. As individuals explain how past life experiences have shaped their current interpretation of a problem now, this serves to mark out their individual way of responding and to lend greater integrity to their efforts.’ Patients and nurses construct personal stories about the meaning of their circumstances (Price 2013). Exploring narratives is a
central practice of narrative ethics, which involves the exploration of personal stories, and clarification of the values, beliefs and moral choices that inform such personal stories (Davis et al 2012). The aim of narrative ethics is to understand what motivates and sustains the behaviour of individuals and the meanings they have ascribed to the actions of others (Davis et al 2012). Nurse leaders explore narratives to highlight areas of misunderstanding and identify root causes of conflict in nurse-patient encounters (Davis et al 2012). Nursing research has shown that the meaning nurses ascribe to patient behaviour affects the ways in which they respond to patients. Nurses responded with greater patience and calmness when they could empathise with patients who demonstrated violent behaviour (Luck et al 2008).
Conflict resolution
Serving as a third-party mediator of conflict is one way for nurse leaders to resolve difficult nurse-patient interactions. Often, nurses embroiled in difficult nurse-patient encounters are dealing with negative feelings of anger, frustration, anxiety or guilt (Fiester 2012). As a stakeholder in conflict, they might not have the perspective or patience to also be able to mediate that conflict (Fiester 2012). Nurse leaders can step in with objectivity and emotional detachment to create a third story, which is a version of events on which both stakeholders can agree (Fiester 2012). Mediation enables the nurse leader to disrupt a pattern of blame and shame, and redirect the efforts of the nurse and the patient towards co-operative problem solving (Abbott 2012). Four mediation techniques for nurse leaders to employ are: listening for understanding, reframing, evaluating the definition of the problem, and creating clear agreements (Gerardi 2004). First, the nurse leader listens to the nurse and patient with the aim of learning what emotions, values and needs are contributing to the conflict. When blaming statements arise, the nurse leader helps to reframe the problem by acknowledging the emotion behind accusations of culpability, removing inflammatory language, restating the problem or issue, and seeking clarification or validation from the nurse or patient (Gerardi 2004). Next, the nurse leader characterises the problem in a manner that both the nurse and the patient can accept. Finally, the nurse leader helps to shape agreement between the nurse and patient. Complete time out activity 3
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Strategies for preventing difficult nurse-patient encounters Nurse leaders can take various approaches to prevent difficult nurse-patient encounters. Several effective strategies include training nurses in how to negotiate difficult encounters, reducing workday time constraints to allow time for nurses to know their patients as individuals, and identifying patients at risk of exhibiting negative behaviour (Table 2).
Training nurses
Prevention of difficult nurse-patient encounters begins with fundamental elements of respectful interactions. This includes approaching patients politely with positive regard, listening actively, responding objectively, sharing power, avoiding judgement and refraining from labelling patients when communicating with other professional caregivers (Wolf and Robinson-Smith 2007). Training nurses in how to negotiate difficult nurse-patient encounters has been proven to boost their confidence to enhance patient care (Brunero and Lamont 2010). Nurses who completed a scenario-based electronic-learning
module self-reported increased confidence, knowledge and skill combined with decreased interpersonal stress in managing difficult interpersonal interactions (Brunero and Lamont 2010). The self-other-setting (SOS) conceptual model has been proposed for developing curricula to train nurses in high quality nurse-patient interactions (Farrell et al 2010) (Table 3). The SOS model involves helping nurses to consider the multiple domains that contribute to difficult nurse-patient encounters and meet learning objectives at two levels of critical thinking: understanding and application (Farrell et al 2010). First, the nurse is challenged to reflect on how his or her own attributes and behaviours contribute to conflict and cause him or her to respond negatively to the patient. Next, the nurse is asked to consider attributes of the patient that contribute to difficulties. Finally, the nurse is tasked with understanding attributes of the healthcare setting that promote difficulties, including the nature of the physical environment, time constraints and social expectations for patient compliance.
TABLE 2 Leadership strategies for preventing difficult nurse-patient interactions Strategy
Rationale
Training nurses in high quality nurse-patient interactions
Using scenario-based learning to train nurses in how to negotiate challenging patient encounters improves the skill level and confidence of nurses.
Reducing workday time constraints of nurses
Ensuring that nurses have sufficient time to get to know patient preferences and values and offer individualised care to patients reduces conflict triggers.
Identifying patients at risk for stigmatisation via formal screening tools and/or nurse leader patient rounds
Screening patients for early warning signs of stigmatisation allows for targeted prevention and swift intervention.
TABLE 3 The self-other-setting conceptual model for training nurses Domains Self
Other
Setting
Understanding
Build understanding of how the nurse’s values, emotions and communication skills contribute to difficult nurse-patient encounters.
Build understanding of how attributes of the patient and the patient’s patterns of responding to illness contribute to difficult nurse-patient encounters.
Build understanding of how cultural and physical attributes of the care environment contribute to difficult nurse-patient encounters.
Application
Promote application of professional values, positive regard and expert communication skills.
Promote application of advocacy and respect for the patient’s perspective.
Promote application of environmental management skills.
Levels
(Adapted from Farrell et al 2010)
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CPD nursing ethics
4 Consider how you would apply the self-other-setting conceptual model to the development of an education project in your practice area. Write one learning objective for each learning domain.
Implementation of the SOS model is best achieved with scenario-based learning which is delivered via mixed modalities (Farrell and Salmon 2009). Scenario-based learning includes application exercises and opportunities for learners to try out techniques in practice. The use of structured reporting forms to monitor difficulties and consequences of learning application combined with supported resources assist scenario-based learning. For example, learners could be asked to keep journals or complete process recordings of their implementation of learning objectives in practice. Learners and instructors could review logs of applied learning jointly and discuss how to improve interactions in the future. Mixed modalities appeal to diverse learner needs and may include both internet-based and face-to-face learning (Farrell and Salmon 2009). Complete time out activity 4
Reducing workday time constraints
Root causes of nurse-patient difficulty identified through qualitative study include not knowing the patient and workday time constraints (Macdonald 2007). Ensuring
that staffing levels allow nurses adequate time to interact directly with patients is one way in which nurse leaders can strive to prevent patient stigmatisation. In addition, nurse leaders can develop formal assessment tools for nurses to learn and apply patient preferences and values. This would enhance nurse understanding of patients and circumvent conflict.
Identifying at-risk patients
Identification of patients at risk of exhibiting negative behaviour during their hospital stay is another strategy for preventing difficult nurse-patient encounters. Baker et al (2006) described an assessment tool for recognising red flags, such as extended length of hospital stay, complex multisystem disease process, nurse requests not to care for a patient and conflict regarding plan of care. Patients identified as high risk for negative behaviours received targeted interventions to promote interdisciplinary team-patient collaboration, shared decision making and problem solving. The process of screening and early intervention resulted in a 71% decrease in patient service complaints (Baker et al 2006).
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Patient rounds led by the nurse leader are an effective strategy for promoting positive nurse-patient interactions and identifying patients at risk of experiencing difficult nurse-patient encounters. The aim of nurse leader patient rounds is to demonstrate to patients the hospital’s commitment to providing high quality care, enable information sharing, establish expectations for the hospital experience and to ensure that patient expectations are being met (Studer Group 2008). Nurse leader rounding at pivotal times of the hospital experience – for example, admission, transfer to a new unit or immediately before hospital discharge – improves patient satisfaction and safety (Baker 2010). Complete time out activity 5
Conclusion Stigmatisation is a phenomenon of reducing, discrediting and discounting. Stigmatised patients are regarded by nurses in terms of their perceived deviance from social norms, rather than as holistic individuals. Consequently, they experience prejudice and are at risk of receiving impersonal
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and inadequate care. This can create a feedforward action-reaction cycle of nurse-patient opposition. Nurse labelling of patients as difficult is a significant antecedent to patient stigmatisation. Appreciation of the nurse, patient and situation factors that contribute to difficulties in nurse-patient encounters is the crucial first step in preventing patient stigmatisation. All nurses have an ethical and professional obligation to treat each patient as an individual with inherent dignity. Similarly, all nurses have a responsibility to advocate for patients and intervene when stigmatisation occurs. Nurse leaders, in particular, have an important role in addressing patient stigmatisation with proactive prevention measures and timely interventions. Several leadership strategies were considered, including modelling, coaching, exploring narratives, conflict resolution, training nurses, reducing workday time constraints for nurses and identifying patients at increased risk of stigmatisation. Nurse leaders can promote high quality nurse-patient interactions using the strategies discussed in this article NS Complete time out activity 6
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5 Critically reflect on your own practice. How do you prevent difficulties in nurse-patient encounters? List two ways in which you could improve. 6 Now that you have completed the article, you might like to write a reflective account. Guidelines to help you are on page 62.
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