The 'difficult patient' phenomenon in home nursing and 'self-inflicted' illness

Home nurses work largely alone, and consequently, 'difficult patients' can be challenging for them. Understanding of this phenomenon can have a major impact on the quality of care. The aim is to explore how nurses characterise, relate to and interact with these patients. Why do nurses perceive some patients as difficult and what are the consequences for the patient? What are these patients´ expectations of the nurses and their perceptions of illness?

An ethnographic study with 30 participant observations of 12 nurses visiting 146 patients was conducted. A total of 6 interviews were made with 4 'difficult patients' and 11 interviews with 5 nurses.

In the nurses' view, the 'difficult patients' had little insight into their illnesses, denied they were ill and were noncompliant. Some nurses had negative feelings about a patient, regarded the patient as too demanding or found the patient´s personal characteristics repulsive. The difficulty lies in the relationship between nurse and patient. Important health problems of some patients remained unrecognised. The nurses regarded the patients' illnesses as self-inflicted. The patients had low expectations of nurses, lacked knowledge about what to expect of them, and their views on their illnesses differed from those of the nurses. Contributing causes of patients becoming difficult for nurses seemed to be different norms and values and the nurses' work situation.

It is important that nurses communicate their knowledge about the connection between illness and pathogenic social conditions and discuss 'self-inflicted' illness and their role in relation to this. Supervision is suggested. Improved working conditions could lead to fewer 'difficult patients'.

The perspectives of patients should be studied in greater detail.