DESCRIBING a patient as difficult can mean that the clinical status of the patient poses particular difficulty or that the person is difficult. The latter meaning is part of nursing as well as other healthcare provider language. The volume of writing on the topic bears witness to its prevalence and importance. The purpose of this paper is to (a) briefly summarize the literature on the difficult patient, primarily the nursing literature; (b) introduce some novelty into the well-worn phenomenon of the difficult patient by pointing out the locating of difficulty in the patient and why this is problematic; (c) illustrate the construction of harmony and difficulty using data from a study on the origins of difficulty in the nurse-patient encounter; (d) explain the relevance of study findings for emergency department (ED) nurses; and (e) offer nurses another lens from which to view difficulty.

REVIEW OF THE LITERATURE

The Phenomenon of the Difficult Patient

Difficult patients has been the topic of several nursing research studies (Breeze & Repper, 1998; Carveth, 1995; English & Morse, 1988; Johnson & Webb, 1995; Juliana et al., 1997; Laskowski, 2001; Olsen, 1997; Podrasky & Sexton, 1988; Santamaria 1996, 2000), numerous articles in the grey literature (Barnes, 2003; Bartlow, 2005; Baum, 2002; Cook, 2000; Dumoff, 2005; Elliott-Smith, 2006; Fadiman, 1997; Fee, 2001; Garza, 2000; Gorman, 1996; Hirst, 1983; Martin, 2001; Morrison, Ramsey, & Synder 2000; Mystakidou & Tsilika, 2000; Neuwirth, 1999; Nield-Anderson et al., 1999; Potter, Gordon, & Hamer, 2003; Quan, 2000; Sohr, 1996; Wasan, Wootton, & Jamison, 2005), and at least five books (Manos & Braun, 2006; Platt & Gordon, 1999, 2004; Stockwell, 1972; Ujhely, 1963).

Locating Difficulty in the Patient

Most of this work maintains a focus on the patient as the source of difficulty and offers a series of suggestions to healthcare providers to modify patient behaviors. Notable exceptions include the work of Johnson and Webb (1995), Breeze and Repper (1998), English and Morse (1988), and Laskowski (2001). Johnson and Webb found that the act of describing patients as difficult was not unilateral and varied considerably with what was going on in the context of care. These authors called for researchers to look beyond the individual as the sole source of difficulty and to consider how the context of care contributed to patients being described as difficult. In other words, Johnson and Webb found as did sociologist Becker (1966, 1973) that labeling of individuals was an interactional process that varied over time and according to who the players were and to what was at stake in the situation. Breeze and Repper, English and Morse, and Laskowski included patients in their studies and even though they did include descriptors of difficult patients, the patients in the studies reported feeling controlled and that this led them to act in ways that caused them to be labeled as difficult. This finding expands thinking beyond the patient as the source of difficulty to an examination of systems of care factors that may contribute to the construction of difficulty. Russell, Daly, Hughes, and op't Hoog (2003) also found that nurses need to consider the social context when they find themselves describing patients as difficult.

Origins of Difficulty

These findings led Macdonald (2005) to conduct a study not about difficult patients but about the origins of difficulty in the nurse-patient encounter and found that difficulty in nurse-patient encounters was directly related to the time nurses had to provide care. Several factors in the context of care directly affected the time the nurse had. These factors were availability of supplies and equipment, families, who is working, and care space changes such as shortened lengths of stay and complexity of patient illness (Table 1). Most important, Macdonald found that knowing the patient was a precondition to a harmonious nurse-patient encounter. This finding was also confirmed in studies by Tripp-Reimer (1984), Fisher (1989), Tanner, Benner, Chesla, and Gordon (1993), and Liaschenko (1997).

Table 1. Factors in care context

The evidence is accumulating that the interactional process and the context of that process contribute to the construction of difficulty in the nurse-patient encounter. This knowledge needs to be disseminated to nurses so that when they find themselves describing patients as difficult they will know that there is more to what is going on than simply locating the difficulty in the patient. They will be able to take that step back and examine the interaction and the context of the interaction for factors that may be constructing difficulty, and then address these factors.

CASE ILLUSTRATIONS

To help nurses reflect on how harmonious and difficult encounters are constructed, the author presents case illustrations of harmonious and difficult encounters. These illustrations were built from data from Macdonald's study (Macdonald, 2005) on the origins of difficulty in the nurse-patient encounter and reprinted from the original work. The factors that contributed to the construction of harmonious and difficult encounters on a family medicine unit have relevance for EDs as well. An explanation of the relevance to the ED follows the illustrations.

The Case of the Harmonious Encounter

Alyson, RN, arrived on the nursing unit to begin a day shift and heard coworkers say "the unit has a full complement of staff and five third year nursing students" (N5). Alyson checked the assignment. She had six patients and was covering three patients for a licensed practical nurse (LPN) for medications and treatments outside the scope of practice of the LPN. Two of Alyson's patients were assigned to a student nurse. The tape-recorded night report begins. The night nurse reported on a 90-year-old woman admitted last evening in congestive heart failure, taking numerous medications at home, spent a poor night, was confused and calling out for someone, and required a lot of time.

Alyson checked all the patient care plans, collected a previously stocked supply cart, and began rounds by seeing the 90-year-old woman first. She was in tears. Alyson sat down and asked, "how may I help you?" The woman asked for the bedpan, and I said, "okay, sure, no problem." And she looked at me and said, "is it ever nice for someone to say, yeah, okay, no problem, and give me the bedpan with a smile on your face" (N5). You know, things that are just so minute to me as a nurse were so important to her. Alyson later remarked to the researcher how much more cognitively capable this woman was in person compared to the report and the care plan. Alyson explained the unit routine to the woman as well as how often rounds were made and that in the meantime the woman could ring her bell as needed.

Alyson continued rounds; four patients were relatively self-sufficient and reported to the nurse that all was okay at the moment. The fifth patient required complete care and was assigned to one of the students. Alyson and the student discussed the plan of care and explained it to the patient.

This patient he couldn't communicate and when we did his care he would get very agitated. I contacted his next of kin, his mother, and found out he was a huge country music lover. So I got a tape recorder and played his music, and during his care he made eye contact with us. He would not look so afraid and he would be a lot more relaxed and the care would go a lot better. (N6)

At the completion of rounds, Alyson felt as though each patient had what was needed at the moment and checked with coworkers to see if anyone needed immediate help. Staff in general felt they were meeting their respective patients' needs. Alyson returned to check on the 90-year-old woman and found a family member present who had many questions. Alyson explained that medications and treatments had to be done now for other patients and scheduled a time to come back and speak with the family member. Alyson's day continued in a pattern of administering medications, treatments, and spending time with patients and families as needed. "A nurse that is compassionate, the patient is different. You know, that nurse would bring life back to that woman's eyes (P10). "I think it's the communication, talking to nurses, that they can sit down for five minutes and just even hear somebody, because it really helps" (P3).

Alyson regularly checked with coworkers to make sure all was well with them and at the end of the shift had a good feeling about the care delivered today. Alyson had the time to get to know the patients, encounters were harmonious, and temporalities were reconciled.

This case depicted the contextual factors necessary for the nurse-patient encounter to be a harmonious one. Alyson worked a shift on an adequately staffed nursing unit, had time to get to know the patients and families, worked as a team member checking with other staff, and supplies were available as needed.

The Case of the Difficult Encounter

McKenzie, RN, arrived on the nursing unit to begin a day shift. It was snowing that morning and the drive to work was stressful. The first thing overheard was, we will be working one RN short today. This meant "we all had one extra patient so that sets you off on the wrong foot" (N1). There were two floating RNs sent to replace sick calls; the third sick call was not replaced because of a shortage of RNs and McKenzie was covering the medications and treatments of an inexperienced LPN. The tape-recorded night report began and McKenzie was wondering how all of the work was going to get done. The night nurse reported that a terminally ill patient was to be admitted momentarily coming from the ED and the patient had a large extended family that wanted the best care possible. Before the report ended, the patient arrived and McKenzie went to greet her.

I had a patient who was dying that had just come from Emerg. That was kind of all new for the family, so you're trying to spend time with them. I was covering the patients of the LPN. A patient of the LPN was having difficulty breathing. The LPN came and got me to help her. So I went in the room and she was choky, anxious, I set up the suction, I kept reassuring her. I was being hauled in two different directions. About ten minutes later a relative of the patient who was short of breath came along and said she doesn't want you around because she feels you are not very compassionate. (N7)

McKenzie was devastated by the criticism and knew that somehow time was needed to go and listen to this patient and family and to try to explain the situation, but when? For the moment, the situation was not reconciled and a difficult encounter was constructed.

McKenzie finished rounds on the assigned patients and feeling pressed for time decided that some baths must be started in order to get through the work today. The first patient chosen for bathing was an elderly woman. "I remember washing her up, getting her into the chair, all of a sudden she said 'you're hurrying me.' She didn't even want to get up. I was pushing to get all this done so fast" (N1). McKenzie realized how upset the patient was and apologized to the patient for hurrying her and not listening to her.

McKenzie now returned to check on the woman who was dying surrounded by her family. McKenzie's first thought was this woman should be on Palliative Care where she and her family could be given the care and time they needed. The patient asked for something for pain and the nurse left to check with the medication nurse to have this taken care of. Arriving in the medication room, McKenzie finds Pharmacy has not completed the unit stocking and the medication nurse went to Pharmacy to get the most needed medications. McKenzie began to prepare the pain medication, the floating RNs had numerous questions for McKenzie, and it took some time to get back to the terminally ill patient and upon arrival in the room the family members were annoyed at the delay in treatment and asked to speak with the head nurse.

McKenzie realized it was only 10 AM and already two nurse-patient/family encounters resulted in difficulty. McKenzie did not get back to speak with the patient and family encounter that started the day. The entire shift was like this and consequently, staff did not feel good about themselves and patients did not receive the care they believed they needed in a timely fashion.

Despite Mckenzie's best effort, there was not enough time to get to know the patients. Medications were not available to be delivered on time and patients and families did not get the nursing time they believed they needed. Staff did not know each other and were not able to work effectively as a team and attempted to control patients or to justify a lack of time by saying the patient should be on a different unit to get the appropriate care. Although this study was conducted with patients from a family medicine unit, several of them had ED visits or were admitted via the ED. Do the factors that contributed to harmony and difficulty in the study setting have relevance for ED nurses? I believe they do and an explanation of how each of the factors is relevant in ED nursing care follows.

FACTORS AND RELEVANCE TO ED

Availability of Supplies and Equipment

The availability of supplies and equipment is the first of four factors in the context of care that consumed considerable nursing time that could have been spent with patients. This factor was created by several systems-related sources. Pharmacy installed a new computer system interface with the expectation that dispensing time would be reduced; however, the opposite happened, causing constant delays in delivering medications to units, and medications missing, causing nurses to spend time calling for medications and even walking to pharmacy to get what they needed. One nurse reported, "Pharmacy is the most frustrating because we're always waiting for pills" (N7).

The unit was equipped with a portable vital sign unit to measure temperature, pulse, blood pressure, and oxygenation. When this machine worked, staff loved it because it saved time. Unfortunately, it frequently broke down and biomedical insisted staff use was the problem and not the machine. The hospital computer system failed at times or required downtime, necessitating nurses conduct work manually, which took more time because it was difficult to recall how to do procedures manually that were usually done electronically. The hospital had also contracted laundry to a new service, resulting in the undersupply of such basics as face cloths and towels, again necessitating that nurses take time to somehow get the supplies they needed.

When the researcher discussed with nurses the lost minutes and hours related to the lack of needed supplies and equipment, most nurses readily described their frustration. Nurses did not automatically relate time constraints to these factors but rather automatically expressed the need for additional staff.

The system problems that created the factor of availability of supplies and equipment might also have affected the ED of this same hospital. The degree of effect may vary but the same factor would be present. One study participant recounted how difficult it was to go to the bathroom in the ED, especially if you needed help. In addition, the ED did not have bedside commodes like the in-patient units. One patient reported, "where I was placed in the ED, the washroom at that end was out of service, so I would need to go through the whole place to the other side and of course, like if I stood up, I was incontinent right away. The nurse said 'use the bedpan'" (P12). Many EDs have installed toilets in individual rooms. EDs would like to have them for all patients who are being monitored, for those who are unable to walk to a bathroom, to enable the independent to remain so, and to diminish the amount of traffic in an already heavily trafficked area (Gerber Zimmermann, 2006).

Families

Nurses learn in their course of study the importance of families in the lives of patients and that the two cannot be separated. Despite this, nurses in the study felt ambivalent. For example, when pressed for time, some nurses chose to care for the patient without regard for family members. This choice often led to difficulty between the nurse and the family members.

Family presence in the trauma room has also generated considerable debate over the past two decades (Parkman Henderson & Knapp, 2006; Mangurten et al., 2006; Morse & Pooler, 2002). Initial resistance was based on "fears families might lose control and interrupt care, violate patient confidentiality and privacy, make healthcare providers uncomfortable, impose limits on medical staff training, and increase the risk of litigation" (Mangurten et al., 2006, p. 226). These fears have not held up in studies on family presence. Several studies revealed considerable benefits to families in relieving their anxiety and enabling families to feel like a unit (Meyers et al., 2000; Powers & Rubenstein, 1999; Robinson Mackenzie-Ross, Campbell-Hewson, Egleston, & Prevost, 1998). The development of consensus guidelines for family presence during pediatric invasive procedures and cardiopulmonary resuscitation (Parkman Henderson & Knapp, 2006) is clear evidence of the importance and growing presence of families in emergency and trauma care and nurses will need the time necessary to inform, educate, and support families to attain positive outcomes for patients and for themselves.

Patient participants in this study did not report any resistance to family member presence in the ED. These patients were glad to have a family member present to help in any way possible because the nurses were too busy to do nonurgent care. Patients and families would like to have had more nursing time for personal and supportive care.

Who Is Working

Nurses in the study described cogently how much a shift varied based on who was working. One nurse explained that when she arrived and learned that certain nurses were working she just knew that no matter what happened the shift would be a good one. "Even if we were too busy to give patients all the care they needed, each patient would get all there was to have because we worked together, everyone checking with everyone, and helping each other out" (N8). Conversely, nurses reported that when they did not work well together patients did not receive as much care and that nurses with the sickest patients were left to do the best they could. This was evidenced by nurses not checking to see if a colleague needed help to manage patient care and finishing a shift and leaving colleagues with unfinished work to finish up on their own.

This situation can occur in any work setting and Kelly (2005) in writing about relationships in emergency care reminds nurses to work as a team. Kelly describes the failure to work as a team as a cause of failure in nurse-patient relationships. Findings from this study support this and report it as a factor in the origins of difficulty in the nurse-patient encounter.

Nurses in this study described what they believed to be a lack of mutual understanding between how nurses work in EDs versus in-patient units. ED nurses maintained that nurses in other units did not report discharges in a timely fashion, leading to longer patient stays in ED. The units maintained that the timing of reports called in by the ED and patient arrivals was often done untimely (i.e., at change of shift). These system problems consumed valuable nursing energy and time. The origins of the misunderstandings need to be uncovered and addressed to contribute to the smooth functioning of all care areas.

Care Space Changes

This fourth factor in the origins of difficulty in the nurse-patient encounter represents how the nurses described the changes in giving care on the unit. Nurses described patients as having several comorbidities, complex, and taking numerous medications. During their stay, they were treated for the most pressing medical concern and then discharged as quickly as possible. Nurses believed they needed more time to hear about patients' concerns, institute patient teaching, and generally provide better emotional support to their patients. The shortened length of stay and the generally weakened condition of patients during their hospital stay prevented their needs from being met. Frequently, at the time of discharge these nurses knew these patients would likely be readmitted and perhaps be sicker on readmission since their needs were not addressed.

The ED landscape has changed considerably over the past two decades. EDs have become part of a safety net for weaknesses in the health and social systems. Patients who have no family physician, who are homeless, and the mentally ill rely on EDs for their acute care needs.

In addition to providing trauma and emergency care, EDs also respond to bioterrorism events and provide forensic healthcare. The aging of the population means many more elderly patients in EDs and healthcare professionals may not have the comfort level with this population needing nonurgent care (Kelly, 2005).

The need for ED nurses to understand how societal forces have created these changes in their care space is more important than ever before. A growing number of ED patients are not there due to an emergency and they want to be listened to, to have their stories heard and basic care needs met. Two study participants speak of their ED visits, "the last time I was in the ER it was wonderful. They tended to me, they weren't busy" (P2). "I was in the ER, I was feverish, I would have liked to have got cleaned up, I didn't get more than a few minutes of anyone's time" (P12).

NURSING CONSIDERATIONS

The participants in this study all valued time. Nursing staff believed that when they had the time they needed, the nurse-patient encounter went well (i.e., all their concerns were reconciled), including time. Patients felt that when they received the care they needed in a timely fashion all was reconciled.

These findings are important for nurses to know when they deliver patient care. When patients are described as difficult this situates the difficulty uniquely within the patient rather than the situation. The literature reviewed provided ample evidence that difficulty is constructed in the encounter and that the encounter is influenced by what is happening in the context of care. When nurses perceive that difficulty is arising, this serves as a flag to begin to examine the encounter and the context of care for factors that are contributing to the construction of difficulty. This identification of factors offers nurses another lens from which to view difficulty. As long as difficulty is perceived to be within the patient, nothing else gets examined or remedied. Nurses need to be alert to difficult encounters, identify what is constructing them, and work toward addressing the factors that contribute to the construction of difficulty.

How then do nurses find the much-needed time to have harmonious encounters? The most frequent response is more staff. This will not address contextual factors that eat up nursing time. Nurses need to clearly delineate lost time delivering patient care in units of time. The example of nurses spending hours obtaining medications from pharmacy was directly related to a system problem, yet nurses did not make the connection that their efforts to obtain these medications were decreasing their time to deliver patient care.

Another area of change might be to have a standing agenda item at regularly scheduled staff meetings addressing patient care delivery time. The institution of such a plan may help identify factors in the context of care that are time related. Many healthcare settings, for example, have electronic patient records. Nurses frequently describe inefficiencies in these systems. These factors must be addressed because there is a cumulative effect with each factor that steals time from patient care. When these circumstances occur, the likelihood of a difficult encounter increases. Lost nursing care hours also need to be tracked to build the case for addressing the cause. In other words, if nursing can demonstrate the patient care hours lost to system inefficiencies, resources can be mobilized to address these inefficiencies. If the information system adds to nurses' work and reduces time with patients, improvements in the system functionalities need to be made. Nurses and healthcare leaders must raise awareness about these lost care hours and initiate processes to address factors that consume patient care time.

CONCLUSION

In conclusion nurse researchers must continue to study care contexts for factors that contribute to unfavorable care outcomes, and to make these factors known to healthcare settings. Having the time to get to know patients and to meet their needs is a prerequisite to a harmonious nurse-patient encounter. Nurses need to be diligent in monitoring the factors that consume valuable patient care time and determine if these factors are justified or if they need to be addressed in order to have the time to get to know the patient and set the stage for a harmonious encounter.

REFERENCES