The Context of Patients’ Lives

I try to touch base with the clinic nurses each day before patients and physicians (in that order) start arriving and the usual busyness of the day takes over. A recent early morning conversation centered on one nurse’s frustration with the spouse of a man who had been treated in another city and who was now under the care of a physician at our clinic. The woman had been calling the nurse repeatedly since her husband had returned home after the procedure. He was having complications, and she wanted something to be done about this immediately. The nurse was receiving text and email messages from the physician, who was also being contacted by the man’s spouse, and his frustration was doubling up the effect on the nurse. The physician had agreed to provide follow-up care for this man and, frankly, I was somewhat surprised at the fuss this was creating.

I suggested to the nurse that she try and put herself in the position of the spouse of the man who was experiencing what sounded like significant side effects. I have found that if you try to personalize a frustrating experience, you can generally defuse an acute response. I imagine that the spouse was scared and perhaps had not been adequately prepared for what might happen after the procedure. Her husband was likely in pain and/or agitated, and she was bearing the brunt of his emotions. They had been told that follow-up was going to happen with the physician at our clinic, not where he was treated. Although they may have had unrealistic expectations of the care we were going to provide, this man and his spouse still needed to be cared for. However, the nurse and perhaps also the physician were seeing this couple as difficult and/or demanding and, instead of seeking resolution, their frustration was making the situation worse by deflecting and ignoring what was clear to me as a cry for help.

I have written before in this space about so-called difficult patients (Katz, 2013), and I know that these patients are often referred to me, in part, because I like a challenge. However, what I think I bring to the table in caring for these patients is recognition that it is usually the context of their life that creates the situation where their actions are judged as difficult. The context may be dictated by the particular social determinants of health—poverty, lack of education, early childhood experiences, employment—that influence their experience of illness. Lack of social support networks or plain loneliness can profoundly affect how a person deals with his or her diagnosis, treatment, and recovery. One of the greatest gifts of being a nurse, for me, is the ability to consider the context of a patient’s life and how that affects everything about his or her illness experience.

In the graduate course that I teach, we revisit the nursing metaparadigm of health, person, nursing, and environment. For me, environment is about more than where a person lives (external environment) or their genetic makeup (internal environment); it is also their social environment that encompasses their relationships, employment, and education. These all are reflected in the context of the person’s life, just as we bring the context of our life into our work each and every day. The context of patients’ lives makes nursing the fascinating profession that has kept me engaged for so many years. That extends to my time as a full-time faculty member, where the context of the students’ lives brought understanding to their, at times, challenging actions. I recall a student who consistently slept through my 8 am class on a Monday morning. When I asked him about his life outside the university, I learned that, at age 18 years, he was the breadwinner for his family, and he worked the night shift over the weekends as a nursing aide and then came to class without proper sleep for more than 72 hours. No wonder he could not stay awake!

To return to the agitated spouse who was causing problems for the nurse, one of the other nurses suggested that she call the physician who did the procedure and insist that the man be seen in follow-up, regardless that the physician’s practice was 1,500 miles away. To me, this was obviously not a viable solution and likely would only inflame the situation, particularly because the patient had been told that follow-up care would be provided closer to home at our clinic. I once again suggested that we all think about what the context of this couple’s life was like. He was in pain, anxious, and unsure of what to do. His spouse had reached out to us for help because she, too, was anxious and unsure. That is not a good place to be. Instead of deflecting, delaying, and inflaming the situation, we needed to provide what care we could to minimize their anxiety.

For me, it is always about the context when patients are “difficult,” and labeling is not helpful. What is helpful is to understand the context, and, in this case, we could try to treat their anxiety with understanding and offer advice—or better yet, an urgent appointment. I sincerely hope that is what happened next. I am going to make it my business to find out.

About the Author(s)

Anne Katz, PhD, RN, FAAN, is a clinical nurse specialist at the Manitoba Prostate Centre and a sexuality counselor for the Department of Psychosocial Oncology at CancerCare Manitoba, both in Winnipeg, Manitoba, Canada. Katz can be reached at ONFEditor@ons.org.