Evidence-based nursing
Good or bad patient: Labels that affect the patient's ability to make decisions
Buen o mal paciente: etiquetas que impactan en la capacidad de toma de decisiones de los pacientes
Jesús Molina-Mula
Departamento de Enfermería y Fisioterapia, Universitat de les Illes Balears, Palma de Mallorca, Spain
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It is also a reflection on the patient decision-making capacity within a clinical environment.</p><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Method:</span> The study entailed interviews with patients at an internal medical clinic in Switzerland. The findings were compared with a critical review of published literature.</p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Results:</span> The study provides a picture of incidents, nurses’ behaviour patterns which stimulate or inhibit patient participation and the reactions of the patient to this behaviour. It reflects that the professionals prefer the patient role to be passive and submissive and that they comply with imposed therapeutic indications. The approach the patient has towards care will determine whether they are labelled as a good or bad patient.</p><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Conclusion</span>: By reinforcing the patient's capacity, autonomous decision making may be optimised. By emphasising personal and spontaneous care, the nurse will be freed from making presumptions regarding patient needs and autonomous decision making by the patient will be generated.</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Comment</span><p id="par0035" class="elsevierStylePara elsevierViewall">The study analyses nurses’ behaviour in the clinical environment which has an influence on patient participation, employing the Critical Incident Technique. This collects observations or discussions regarding human behaviour of critical importance. To do this, the authors conducted 17 semi-structured interviews with patients from an internal medical unit in a general hospital.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Some of the most relevant issues of note are that the nurses limit active patient participation, that they offer very little information and that they only ask for an agreement from the patient under certain circumstances and on the most basic treatment. Situations arose where the conformist patient was better treated by the nurse whilst in contrast, the worse the relationship, the more participation in care was limited to unimportant matters.</p><p id="par0045" class="elsevierStylePara elsevierViewall">One of the main limitations of this study was that patients did not distinguish the nurse from other professionals when issues were explained and it was therefore difficult to ascertain whether reference was only made to the nurses’ behaviour. This issue is resolved below when we compare behaviour with other studies of this kind.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Research studies confirm that the nurse prefers a submissive and passive patient for compliance of therapeutic indications. A patient who is easygoing and fully trusts the professional when they are hospitalised, figuratively speaking, becomes the property of the professional and is therefore dominated by them.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Two types of patient concepts appear in our clinical environment, the <span class="elsevierStyleItalic">good patient and the bad patient.</span> The <span class="elsevierStyleItalic">good patient</span> is the one who accepts their illness, who does not demand much information from the professionals, who does not demand attention, who accepts the rules and regulations of the institution, who appreciates the work the nurses do and who is collaborative and participative in whatever care is imposed.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Cribb and Entwistle<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> suggest that this submissive patient relationship responds to a paternalistic care concept, where the professional justifies their dominance as a form of patient protection. Kleiman et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> differentiate between an active/passive authoritarian model which imposes hierarchical will over the subjects who would prefer to take their own decisions and a protective paternalism considering the patient as incapable of taking decisions on the disease process.</p><p id="par0065" class="elsevierStylePara elsevierViewall">In contrast, the common reference to a <span class="elsevierStyleItalic">bad patient</span> which features in the nursing register and in the shift changeover is that of a “demanding” or “very demanding” patient. This consideration unleashes a paradoxical situation because once a patient has been labelled as “demanding” an alarm bell goes off in the rest of the staff and a series of preventative confrontation strategies are put into place with regards to that patient. Patients are demanding or bad when they increase the work load of the nurse in general, with regard to what he or she considers they should dedicate to each patient according to their pathology. This patient does not comply with the orders of the professionals, refuses treatments and care which is imposed and demands a great deal of information.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Whilst a good relationship with the patient is accompanied by mutual confidence, cordiality, closeness, resolution of doubts, advice, empathy and even friendship<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">5,6</span></a> the bad relationship is accompanied by a distancing towards the patient, with continuous conflicts, low communication and a reduction of time dedicated to them. Labelling a patient as good or bad has a direct impact on the quality of care and predetermines a certain role for nursing the patient. The nurse recognises that a good relationship improves the quality of the outcome and cure of the patient. A bad relationship not only worsens quality of care but also limits the patient's decision-making ability.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">It is interesting that this point reflects on to what extent relationships of power are key, given that the autonomy of the patient in taking decision depends on the exercise of the nurse's power and the role which each one acquires in the relationship. A domineering-dominated dichotomy stands out here (<a class="elsevierStyleCrossRef" href="#bib0070">6</a>:133), where the nurse wields power, using strategies of manipulation, persuasion, coercion and therefore exercises a paternalistic or expert role, of domination. The nurse-patient relationship is unequal and hierarchical, leading to submission and subjugation of the patient and is a privileged situation for the professional in which to exercise power, according to Foucauldian understanding.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">7,8</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The nurses exercise power through a series of mechanisms such as normalisation of care, homogenisation through protocols, vigilance and control of constants and clinical complications, submission to medical orders, subjugation to therapeutic instructions, the clinical vision which determines what to do and when, control of spaces and the use of times through regulations, reward for good behaviour of the patient and sanctions when the patient does not assume a passive role.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">To conclude, the aim of care strategy normalisation is for the patient to follow a regularised pattern and thus achieve conformity within a care health structure. These normalisation strategies prescribe specific patterns of behaviour and also classify the patients into “good” and “bad” according to the outcome of different studies. In this way, they define what is normal or not, what is acceptable or unacceptable, what is better or worse. This normalisation provokes homogenisation of the patient whose identity is threatened, hindering their individualism and singularity.</p><p id="par0090" class="elsevierStylePara elsevierViewall">If genuine patient autonomy is to exist for the taking of decisions, the nurse must therefore establish a relationship of equality, strengthening the patient's ability to optimise autonomous decision-making. Focus must be placed on personal and spontaneous care, with consideration of the patient as an individual, and without any presumption of their needs being made. The patient would thus feel that the nurse understood them and that their decision making was autonomous.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "sec0005" "titulo" => "Comment" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-03-22" "fechaAceptado" => "2017-03-30" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Molina-Mula J. Buen o mal paciente: etiquetas que impactan en la capacidad de toma de decisiones de los pacientes. Enferm Clin. 2017;27:203–205.</p>" ] ] "multimedia" => array:1 [ 0 => array:5 [ "identificador" => "tb0005" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0010" class="elsevierStylePara elsevierViewall">Larsson IE, Sahlsten MJE, Segesten K, Pios KAE. Patients’ perceptions of nurses’ behaviour that influence patient participation in nursing care: A critical incident study. Nursing Research and Practice. 2011; 2011(1): 1–8. <span class="elsevierStyleInterRef" id="intr0010" href="doi:10.1155/2011/534060">doi:10.1155/2011/534060</span>.</p></span>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Patients’ perceptions of nurses’ behaviour that influence patient participation in nursing care: a critical incident study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "I.E. Larsson" 1 => "M.J.E. Sahlsten" 2 => "K. Segesten" 3 => "K.A.E. Pios" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Nurs Res Pract" "fecha" => "2011" "volumen" => "1" "paginaInicial" => "1" "paginaFinal" => "8" "itemHostRev" => array:3 [ "pii" => "S0140673615612521" "estado" => "S300" "issn" => "01406736" ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0050" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Available from: <span class="elsevierStyleInterRef" id="intr0015" href="http://www.tdx.cat/bitstream/handle/10803/112120/tjmm1de1.pdf;jsessionid=A56059EE151B5B3401099438221F3F54?sequence=1">http://www.tdx.cat/bitstream/handle/10803/112120/tjmm1de1.pdf;jsessionid=A56059EE151B5B3401099438221F3F54?sequence=1</span>" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Saber, poder y cultura de sí en la construcción de la autonomía del paciente en la toma de decisiones: relación de la enfermera con el paciente, familia, equipo de salud y sistema sanitaria [tesis Doctoral]" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J. 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| 2023 March | 5 | 17 | 22 |
