Struggling for control: the care experiences of ‘difficult’ patients in mental health services

Abstract

Although there is increasing recognition of the existence of 'difficult' patients who present particular challenges to mental health nurses, no research has been conducted into their perceptions of services and their experiences of care. This study identifies mental health service users who are defined by nurses as 'difficult' and explores their perceptions of their care experience. The results support earlier studies which suggested that 'difficult' patients challenge nurses' competence and control: despite their different roles both nurses and 'difficult' patients were aware of the struggle to gain or retain a notion of control. Respondents were able to identify the qualities of nurses and nursing interventions which had a positive effect on their care experience. Where nurses were perceived to demonstrate respect, time, skilled care and a willingness to give patients some control and choice in their own care, feelings of anger were reduced. These findings are discussed within the conceptual framework of 'power over' and 'power to' and implications for practice and research are considered.

Nurses’ responses to expert patients: The rhetoric and reality of self-management in long-term conditions: A grounded theory study

“…Previous studies have identified the characteristics of patients perceived as problematic by British nurses (Kelly andMay, 1982, Stockwell, 1984), and more recently have linked the concept with value judgements made by the nurses (Johnson and Webb, 1995) and nurses' perceptions of patient's refutation of their competence (Breeze and Repper, 1998). However, what appears unique to this study is that nurses appear challenged by reasonable queries regarding possible self-management strategies, and rather than being accepted as a genuine suggestion, the patients described in the scenarios and within the data were viewed as non-compliant in the narrowest sense (World Health Organization, 2003).…”

“…There also appeared to be a lack of trust from the nurses regarding patients' abilities to self-manage responsibly, directly impacting on their facilitation of patient involvement in decision-making (Entwistle, 2004). Paradoxically, it was the perceived sense that the patient did not trust the abilities of the nurse and was therefore questioning the suggested treatment (Kraetschmer et al, 2004) that resulted in the nurses' feeling challenged with a subsequent loss of self-worth (Breeze and Repper, 1998).…”

“…As expert patients become increasingly common, professional roles need to change (Salvage, 2002) in order to respond to peoples' desires to have some meaningful control over treatment and to be treated as a valued partner in care (Breeze and Repper, 1998). Bodenheimer et al (2005) describe the essence of the chronic care model as being the interaction between informed, activated patients and a prepared, proactive team.…”

Student psychiatric nurses’ approval of containment measures: Relationship to perception of aggression and attitudes to personality disorder

“…Based on this previous evidence of a link between APDQ scores and cognition about containment (and practice around violence prevention), and as there is a link between personality disorder and the disturbed behaviour of inpatients (Hildebrand et al 2004), it seemed likely that there would be some relationship between APDQ and evaluation of containment methods. Personality disordered patients are highly challenging, elicit negative feelings and responses from staff (Morgan and Priest, 1991), are considered by nurses to be difficult to manage (Breeze and Repper, 1998), exhibit behaviours likely to harm themselves of others (World Health Organisation 1989), and are thus likely to be subject to containment measures.…”

Who Says There’s a Problem?

“…Breeze and Repper' s study of nurses explores the theory of power, and they conclude "threats to the nurses' competence and control were important components when defining patients as difficult." 13 Trexler made a similar conclusion: "Nurses' self esteem, belief systems, clinical experience and tolerance levels may also affect the probability of labeling." 14 Organizational and societal influences also play a role in labeling.…”