discussion

E M P I R I C A L S T U D I E S doi: 10.1111/j.1471-6712.2011.00908.x

Emotional distance to so-called difficult patients

Jette Joost Michaelsen Health Services Research Unit, Department of Public Health, University of Copenhagen, Copenhagen, Denmark

Scand J Caring Sci; 2012; 26; 90–97

Emotional distance to so-called difficult patients

Purpose: To explore nurses’ relationships with patients they

regard as being difficult. How do nurses feel about such

patients and relate to them, and what are the conse-

quences for nurse and patient?

Design and methods: A qualitative study inspired by herme-

neutic phenomenology was conducted. The data were ob-

tained through participant observation and interviewing in

a home nursing unit in a Danish municipality. During an

initial 3 month period, eighteen participant observations

were conducted with 12 nurses during their visits to 96 pa-

tients. During the following 3 months, 12 more participant

observations were made with three nurses visiting 50 pa-

tients. Four of these patients whom the three nurses found

difficult were selected and six interviews conducted with

these patients. Eleven interviews were conducted with five

nurses. Patients’ case records were studied and four meet-

ings with the staff were arranged to discuss the findings. Data

collection lasted 18 months in all.

Findings: Three strategies were identified: persuasion,

avoidance (emotional distance), and compromise. Inter-

estingly, in the relationship with a particular patient, the

avoidance strategy did not necessarily represent the ter-

minal stage, since a nurse could revert to the compromise

strategy. Some of the nurses experienced painful emotions

regarding these interactions.

Conclusions: The avoidance strategy (emotional distance)

resulted in important social and health problems of some

patients not being recognized, and some nurses using it

expressed the fear of losing contact with their emotional

lives. The compromise strategy gave possibilities for dia-

logue.

Study limitations: The focus was mainly on the nurses and

their perspectives. It would be interesting to study in

greater detail the perspectives of the patients.

Keywords: emotional labour, difficult communication,

so-called difficult patients, home nurses, avoidance,

strategy (emotional distance), compromise strategy,

persuasion strategy, qualitative study, hermeneutic

phenomenology.

Submitted 23 September 2010, Accepted 15 June 2011

Introduction

This article explores nurses’ relationships with ‘difficult

patients’, that is patients the nurses regard as difficult. It

presents a qualitative study of communication between

home nurses and patients, and investigates how nurses feel

about and relate to such patients, and what the conse-

quences are for patient and nurse. The concept of the

‘difficult patient’ used in this article does not imply that

these patients are in fact difficult. Previously, data collected

as part of the same project have been used to understand

the phenomenon of the ‘difficult’ patient. This showed that

a particular patient may be regarded as difficult by one

nurse but not by another, and consequently there is no

unequivocal definition of a ‘difficult’ patient. The difficulty

did not lie in the patient, but in the relationship between

the nurse and the patient (1, 2). Since the nurses were

deeply concerned about their relation to the difficult

patients it is relevant also to explore nurses’ relationships

with these patients.

Selected literature

This section briefly summarizes relevant previous work on

difficult patients, emotional labour, distancing strategies in

nursing and communicative aspects of the nurse-patient

relationship.

‘Difficult patients’

Research shows that patients may be labelled as difficult if

they do not do what the staff tells them, if they cannot be

controlled by them, if they ask too many questions, or if

Correspondence to:

Jette Joost Michaelsen, Health Services Research Unit, Department

of Public Health, University of Copenhagen, Øster Farimagsgade 5A,

building 15, PO Box 2099, DK-1014 Copenhagen K, Denmark.

E-mail: J.Michaelsen@pubhealth.ku.dk

� 2011 The Author 90 Scandinavian Journal of Caring Sciences � 2011 Nordic College of Caring Science

they constantly interrupt the professionals’ routines (3, 4).

Studies show that nurses are provoked by patients who are

overweight, addicted, e.g., to medicine or cigarettes (5, 6),

and that physicians are provoked by patients’ characteris-

tics, e.g., if they are demanding, non-compliant, aggressive

or hostile. Physicians are also frustrated by being unable to

cope with these patients’ medical situations, i.e., to diag-

nose or treat their conditions (7–9). Smith and Hart (10)

discuss how nurses label patients as ‘difficult’ when their

behaviour challenges the nurses’ emotional control of

patient care. Research shows that negative emotions, in

either nurse or patient, make communication more diffi-

cult (11). Limited attention has been given to ‘difficult

patient’–nurse relationships (12) and to the nurse’s

responses to difficult patient behaviours (13).

Emotional labour

Smith (14) found that nurses had to induce, suppress or

subordinate their own feelings to make patients feel cared

for and safe, and analysed this using the concept of ‘emo-

tional labour’. Hochschild defines emotional labour as ‘the

management of feeling to create a publicly observable facial

and bodily display’ (15: 7), a kind of work that requires that

one induces or suppresses feeling in order to create the

right atmosphere in others. Emotional labour is a part of

nursing, and carries with it the risk of the nurse becoming

detached or alienated from her feelings. It has been pointed

out that emotional labour often is seen as a tacit and un-

codified skill, and that further research in this area is nee-

ded (16). Hochschild has analysed flight attendants who, in

common with many other professionals, are socialized to

identify with and engage themselves in other people. She

finds emotional labour potentially good; as she says, no

customer wants to deal with a flight attendant who avoids

eye contact in order to avoid getting a request, but she

raises the question of what the cost of emotional labour is.

In order to survive, the flight attendant must mentally

detach herself from her own feelings and the management

of them. Some ways of performing emotional labour may

be likened to acting. In surface acting one disguises what one

feels, and pretends to feel what one does not – one deceives

others about what one feels, but not oneself, since one is

conscious of it. This is also referred to as a ‘healthy’

estrangement, e.g., the flight attendant pretends to be

happy (and sometimes she gets the feeling), and the pas-

senger reacts as if the flight attendant were happy. In deep

acting one tries to feel what one senses one ought to feel or

wants to feel, and one focuses on what to do to induce the

feeling. Perhaps one feels angry, but this is experienced as

not allowed, and therefore one tries not to act openly on

the feeling; e.g., the flight attendant who suppresses her

anger at a passenger who insults her. She might try to in-

duce in herself the feeling that the passenger is like a child

who drinks too much because of fear of flying, and then she

does not get angry if he shouts at her. In deep acting one

deceives not only others but also oneself. By deep acting

the flight attendant alters herself. The concept of emotional

labour, with surface- and deep-acting, is central in analy-

sing and discussing one of the nurses’ strategies, ‘emotional

distance’ and its consequences for their emotional lives.

Distancing strategies in nursing

Health care professionals use distancing strategies during

difficult interactions through fear of being unable to han-

dle their own negative emotions (17). Nurses who dis-

connect during challenging interactions with a patient may

be unable to communicate with this patient (10). When a

high level of interaction does not result in the patient

adopting the expected norms for behaviour, the nurse

avoids the patient physically and/or psychologically (18).

In addition, emotional labour and emotional engagement

or detachment are in the words of Henderson (19), ‘under-

theorized’ in relation to caring work in general.

Communicative aspects of the nurse-patient relationship

Travelbee has discussed nurse-patient communication

in terms of a human-to-human relationship (20). This

consists of four phases: Original encounter, emerging

identities, empathy and sympathy. Through these phases,

mutual understanding is reached so that nurse and patient

can relate as unique human beings rather than as nurse and

patient. Sympathy is defined as an experience between two

or several individuals, with the capacity to take an active

interest in another person’s feelings. According to Travel-

bee it is not possible to both sympathize and keep a distance

at the same time. Two elements in Travelbee’s work have

inspired the discussion in this article about communication

in nursing: sympathy as an important element in the nurse-

patient relationship, and the perception of this relationship

as a human-to-human relationship.

To summarize, the literature on how the nurse behaves

when responding to difficult patient behaviours is scanty.

According to the literature, emotional labour and emo-

tional engagement or detachment are under-theorized in

relation to caring work in general. In this article nurses’

relations to patients they find difficult are analysed and

discussed with focus on consequences for both nurse and

patient.

Method

Theoretical frame

Hermeneutic phenomenology is grounded in phenome-

nological philosophy. Phenomenology, founded by Hus-

serl, is the study of the life world with the aim of gaining a

deeper understanding of the nature or meaning of

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Emotional distance to ‘difficult’ patients 91

everyday experiences (21). Hermeneutic phenomenology

is both a descriptive (phenomenological) methodology

because it is attentive to how things appear, and an

interpretive (hermeneutic) one, because it claims that no

uninterpreted phenomena exist. This is explained in the

following way: ‘the (phenomenological) ‘‘facts’’ of lived

experience are always meaningfully (hermeneutically)

experienced. Moreover, even the ‘‘facts’’ of lived experi-

ence need to be captured in language (the human science

text), and this is inevitably an interpretive process’ (21:

180–181). If one is a strict follower of Husserl, one may

insist that phenomenological research is pure description

and that interpretation (hermeneutics) falls outside the

bounds of phenomenological research. However some

philosophers make a distinction between phenomenology

(as pure description of lived experience) and hermeneutics

(as interpretation of experience via some ‘text’ or via some

symbolic form), e.g. Silverman distinguishes between

interpretive or hermeneutic phenomenology and descrip-

tive phenomenology (22). An interpretive phenomeno-

logical framework is well suited for the present purpose of

searching for the meaning of the nurses’ experiences. One

way to study human actions and to search for under-

standing of the experiences is to participate in and observe

the nursing care situation and to interview in order to

obtain a person’s own narrative. In the following, partici-

pants, participant observation, interviews and analysis will

be presented.

Participants

Nurses. The study took place in the home nursing unit of a

Danish municipality with 50 nurses and in the patients’

homes. The twelve nurses in the initial participant obser-

vations were between 32 and 63 years old. The nurses

selected for formal interviews were 32, 35, 45, 50, and

63 years old, and one of them male. All had several years

of nursing experience. Inclusion criteria regarding the

initial participant observations were the nurses’ willing-

ness to participate. Inclusion criteria for the subsequent 12

observations were that the nurses had taken part in the

initial observations, that they were willing to continue

participating, and that they had had at least 2 years’ home

nursing experience. Other criteria were that they had been

the head or deputy head nurse of a district, that they vis-

ited patients they found difficult, and that they had at least

1 year’s experience with the selected patients. Inclusion

criteria for interviews were that a nurse had had experi-

ence with the selected patients, and was willing to be

interviewed.

Patients. The patients during the initial participant obser-

vations were from 40 to 90 years old, and most were

around 80 and female. Finally, with advice from the nur-

ses, 4 patients (three female and one male) out of 50 were

selected for interviews. All four patients lived alone. One

was 60 years old, suffering from diabetes and heart insuf-

ficiency. Another patient, who was 80 years old, suffered

from rheumatism. A third patient was 90 years old and

suffered from a slipped disc. The fourth patient was

60 years old, and suffered from arthritis. Inclusion criteria

for interviews were that the patients were regarded as

difficult by a nurse, that they had received home nursing

for at least 2 years, that they were willing to participate,

that they neither suffered from memory loss nor were

senile, and that they were not in crisis.

Data collection

The data were obtained through participant observation

and interviewing (formal and informal). During an initial

3 month period, eighteen participant observations were

conducted with 12 nurses during their visits to 96 patients.

During the following 3 months, 12 more participant

observations were made with three nurses visiting 50

patients with whom the nurses had experienced commu-

nication problems. Four of these patients were selected,

and six interviews conducted with them. 11 interviews

were conducted with five nurses – the three who found

the selected patients difficult and two other nurses with

long experience of the selected patients. Patients were

interviewed in their homes, and nurses were interviewed

in the nursing unit or, in the case of one nurse, in her

home. Patients’ case records were studied and four meet-

ings with the staff were arranged to discuss the findings.

Data collection lasted 18 months in all.

Participant observations. ‘Moderate participant observa-

tion’, where the investigator keeps a balance between

being an ‘insider’ and an ‘outsider’, between participation

and observation, was the research method used to observe

the verbal and non-verbal communication. During home

visits the investigator primarily observed unless contacted

or questioned (23). An observation lasted for about

3–4 hours. Field notes of the communication were made

with a description of the situation, the informal interviews,

a preliminary analysis, interpretations, ideas and new

questions. The purpose of the initial observations was to

understand nurses’ experiences in general with patients,

and to select nurses for further observations. The next 12

observations focused on how these nurses managed their

relationships, especially with patients they regarded as

difficult. In consultation with the nurses, patients they

regarded as difficult were selected for interviews.

Interviews. Informal interviews, e.g., with a nurse on the

way from one patient to another during participant

observations, were made without an interview guide. The

formal interviews were conducted with a semi-structured

interview guide containing themes and questions inspired

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92 J.J. Michaelsen

by the purpose of the study and by the continual analysis.

The interview guide was used to varying degrees,

depending on how the interview proceeded. An interview

lasted for about 1–2 hours. All interviews were audio-

taped, transcribed verbatim, and analysed. The purpose of

interviewing the nurses was to understand their feelings

about and relations to patients they regarded as difficult.

The purpose of interviewing the patients was primarily to

elucidate their experiences with and expectations of the

nurses, and to obtain a deeper understanding of the

patients for comparison with the nurses’ descriptions. The

unit of analysis was mainly the interviews with the five

nurses.

Analysis

The first part of the analysis was characterized by

decontextualisation, governed by the purpose of the study,

and began immediately after the first data (participant

observations of nurses visiting patients) had been col-

lected. One observation or interview was analysed before

the next one took place. The text was read and reread, and

tentative thoughts were recorded. The investigator’s pre-

conceptions of the phenomenon under study (bracketing)

were clarified. To minimize biases, presuppositions were

listed and discussed with a research colleague who was not

a nurse. The material was divided into meaning units

focusing on what the text said without questioning or

looking for a deeper meaning in the statements. Data were

condensed (24). Meaning units were allotted a theme

based on the informant’s own expressions with a focus on

the unique, the individual, the common, and on the

extreme. Themes from, e.g., an interview, created the

frame for a continual reading, but the analysis was open

for new themes to be revealed. The goal was to find

common themes. The various data e.g., the emotions of

different nurses as expressed in interviews were compared

and contrasted with one another, and observations were

also compared with interviews. What was found was

viewed in the context of the nurses’ working conditions

and private lives. Bracketing is neither possible nor desir-

able in the hermeneutic approach used in the last stage of

the analysis, which is characterized by recontextualisation.

The focus then was on how the text could be understood

in the context of the purpose of the study, not on what the

text said. One of the guiding principles in this interpreta-

tion was to consider each part of the text in relationship to

the whole (25). The theme ‘emotional distance’ was re-

lated to theoretical concepts about nurse – ‘difficult pa-

tient’ relationships and nurses’ reactions to difficult pa-

tients as well as to sociological theories of emotional

labour. Finally all the data were compared. The result was

a higher-level synthesis, a description and an interpreta-

tion of the world of the informants seen in relation to the

purpose of the study.

Ethical aspects

Ethical clearance of the study was obtained from The

Bioethics Commitees for the Capital Region of Denmark,

Copenhagen, and consent was given by the patients and

home nurses; in addition, special consent was given by the

patients to study their case records. All identifiers regard-

ing both patient and nurse were removed before analysis.

In referring to both patients and nurses the personal pro-

noun ‘she’ is used irrespective of gender to avoid problems

with lack of anonymity. Nurses felt isolated with their

problems and focusing on phenomena such as ‘difficult-

patient’ and ‘emotional distance’ brought up embarrass-

ment in the nurses. It was important to give feedback,

especially since these issues were not a subject for discus-

sion within the nursing unit.

Findings

Nurses’ relations to and feelings about ‘difficult’ patients

Both the behavioural and the emotional reactions of the

nurses could be classified as three different strategies

which will be referred to as ‘persuasion’, ‘compromise’,

and ‘avoidance’. A given nurse did not always use the

same strategy, but could change from one to another.

Examples of the strategies will be presented, together with

the nurses’ descriptions of their feelings.

Persuasion. The persuasion strategy was characterized by

the nurse believing that the patient would accept advice

and instruction, and attempting to get the patient to adjust

to the patient role expected by the nurse (compliance).

This could be done in different ways, ranging from giving

advice to threatening. This strategy was described in the

nurses’ jargon as ‘to fight against the patient’ or ‘to speak

out loud and play ones trump card’:

There have been periods where she sat down and was

unwilling to do anything. I have been one of those

who have had to raise my voice. It has not always

been pleasant. If she does not agree to a weight-loss

programme and does not want physiotherapy, then

she has to go to a nursing home because we will not

be able to look after her at home, simply because she is

too heavy. Three people will not be able to get her up

on her feet.

The nurse tries to persuade the patient by frightening her

and refusing to let her return home from hospital if she

does not accept advice and instruction about losing weight,

but feels bad about raising her voice. In another example

the nurse tries to persuade the patient to accept her illness

by confronting her:

She does not want to be confronted with being ill. She

misses a lot of things, and when you try to find

solutions, she will not accept them. She does not want

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Emotional distance to ‘difficult’ patients 93

to use a bedpan, and she does not want to use a

wheelchair. When I tell her ‘‘You must acknowledge

that you are so ill’’, then she is not ill. She is all right.

Then she switches off, she becomes a cold fish, you

cannot reach her.

Further examples of this strategy are given below in con-

nection with nurses who use more than one strategy.

Avoidance. This strategy, emotional distance, was in nurse

jargon called ‘passing the buck’ or ‘being a cold cigar’, in a

literal translation of the Danish, which corresponds in

English to ‘being a cold fish’, and appeared to be one of the

nurses’ survival strategies. The avoidance strategy was

characterized by the nurse increasing the emotional dis-

tance to the patient, by withdrawing either psychologi-

cally, (not being emotionally present in the situation), or

physically, (by asking a colleague to take over), a nurse

reaction with more or less negative feelings towards the

patient and with a greater or lesser distance to the patient.

In some situations the distance was further increased by

the patient demanding care and contact, e.g., when the

patient wished to continue talking, the nurse avoided

relating to this, quickly dosed the medicine, and left. The

nurse uses avoidance with a bad conscience because, at the

professional level, she chooses to avoid seeing problems

the patient might have:

I can stand her now because I have reached the level

where I just come in, say something or other, and

leave again. When I wanted to obtain a greater

understanding of her in order to be able to give her

some opportunities, I couldn’t stand her. I have given

up, you get nowhere. I am a cold fish when visiting

her, but I am also afraid that I do not see things that I

ought to.

Another nurse has given up completely in relation to

another patient, and just wants to get out as quickly as

possible:

I leave her in a hurry, because I can use my time much

better somewhere else. I could motivate her to do this

or that, but she will do exactly as she pleases. I think

as the years go by one uses ones energy elsewhere.

In a way it is a relief that a nurse can make a patient laugh:

She is one of those that my colleague cannot stand, so

very often it is nurse X and I who take over. I believe

that she is happy to see us, so it does not bother me

that I am the one who visits her most. I think she has a

sad life, so if I can make her laugh a bit then it is

better.

However, laughter can also be a strategy to make a

distance to the patient’s problems. Besides laughter and

humour, the nurse uses fear, e.g., in connection with the

open sores on the legs:

But she rejects the sores on her legs and behaves as if

they were mine! This is what irritates me, something

that is the most difficult thing about patients. Some-

times I can say: ‘‘That leg is yours not mine!’’ If she is

not ready to help herself, then I cannot heal it. I have

those standard sentences: ‘‘I don’t care because I have

got a steady job’’. Now and then this can frighten

people to do what I want!

There seems to be no dialogue, and the nurse is irritated.

During the participant observations this patient disagrees

with the nurse about the treatment of the legs. The patient

clearly asks for an exercise bike to improve her circulatory

system and thereby heal the wounds, but this request is

ignored by the nurse. The nurse says clearly that fright-

ening is perceived of as a way of making an emotional

distance to the patient. During the visit she talks extremely

loudly and is almost impossible to interrupt, a fact that,

taken together with the other observations, may be

understood as a way of avoiding a dialogue. Another

nurse, in relation to the same patient, also uses emotional

distance, but she is aware that this can be a way of escaping

instead of engaging:

If you like your job, you get involved. I am not very

good at making contact with my friends, and it

remains that way, this is at that level, but I don’t wish

to go further into this, because I know what I have

and what I do not have. It has not always been easy,

not at all! Then it is a great pleasure to care a little and,

in quotes ‘‘to be interested’’. In relation to some of the

patients I do not get in contact. I have other patients

that I am more interested in, but still in a distant way.

That is where I feel the escape, where one should be

able to engage in deeper relationships and not only

with your husband.

This nurse is conscious of the fact that she does not get

involved with the patients, that she avoids engaging in

deeper relationships, and that there is a risk that some of

the patients’ problems are not discovered. She realizes that

her understanding of patients with whom she cannot

communicate is limited. She talks about professional dis-

tance while still caring, and expresses conflict with ideals

for caring and nursing, among other things to engage

deeply in human relationships.

Compromise. This strategy was in the nurses’ jargon called

‘not digging’. The compromise strategy was characterized

by the nurse finding a compromise between using per-

suasion and avoidance. The nurse had given up trying to

get the patient to be compliant, but had not gone so far as

to avoid the patient. This situation could last for a long

time, but could also change. The nurse accepted that the

patient did not listen to her, and she did not question what

the patient said. The following examples show transition

and oscillation between strategies. One example of moving

from persuasion to compromise:

I asked her whether she wanted to go to a physio-

therapist, and she agreed, but actually nothing hap-

pened. Then I must admit that I have done nothing

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94 J.J. Michaelsen

ever since, because she is not able to appreciate the

effect of the exercise programme. She accepts her fate

and we have to live with that.

The nurses have tried without success to make this patient

lose weight. Some nurses still try, but this nurse has given

up and seems to accept the situation. Another nurse

oscillates between avoidance and compromise by listening,

because she is convinced that the patient is in crisis. During

the process of gathering the data, the patient and the nurse

never seem to develop a relationship:

In general she does not stress me, but I can create an

emotional distance that is of no benefit to her.

Sometimes I choose to do this if I feel I cannot do

anything else. But today I really wanted to commu-

nicate with her. I can imagine that she is not able to

get out of the crisis herself.

A third nurse moves from avoidance to compromise with

the same patient. At the beginning of the relationship the

nurse wanted to leave quickly since she could not stand

the continual complaints about pain:

She was a patient I would ask another nurse to take

over, since it was too difficult and irritating. You felt

you were giving medicine to a drug addict. I remem-

ber at the beginning that I wanted to get out again as

quickly as possible. I could not stand this, but this

changed as we built up a relationship. If you focus on

the medicine the whole time, you will get an irritating

woman who just wants her pills. If you turn it around

and say ‘‘This situation is not interesting, and you

know it. What are we supposed to do with one an-

other?’’ you might get another sort of information.

Little by little we changed our relationship. When I

came to visit, the pills were ready on the dinner table,

and she had made tea.

This nurse manages to create a relationship, never

rejecting the patient’s complaints. The nurse asks about

the pains, contacts the physician in order to give a little

extra medicine, and is of the opinion that nurses more

often should let patients administer their medicine

themselves.

Patients’ expectations

In general, the patients seem to be satisfied with the

nurses, and do not seem to have high expectations. At the

same time, they appear to be in doubt about what the

nurses are supposed to offer. One patient does not want to

talk about illness with the nurses. In her view this is done

with the physician and communication with the nurse is

expected to be about what happens in society in general.

Another patient says that she cannot communicate

because one of the nurses talks too much. A third patient

expects the nurse to tell her if the patient is doing

something wrong, but does not regard this as the nurse’s

duty.

Discussion

Methods

Many studies of difficult patient-provider relationships

have identified these by means of questionnaires. This

method gives information on the extent of the problem,

but does not explore explicit relationships in depth, which

was the purpose of this study. Participant observations and

interviews were useful methods for illuminating the phe-

nomenon under study. It was possible to experience and

understand the phenomenon where it took place, in the

patients’ homes, as well as narrated. Use of observations as

the sole data source risks emphasising the researcher’s

subjective perspective. To reduce that risk, participant

observational studies are often followed by interviews

(26), as was done here.

Findings

Consequences of nurses’ emotional distance for patients. The

emotional distance caused the nurse to see the patient

through a filter. For some patients, this resulted in the

nurse concentrating on the physical aspects of illness and a

lack of interest in the patient’s view of the causes of illness

in the context of their lives. In one case the avoidance

strategy resulted in serious physical symptoms being

overlooked. Previous research has shown that nursing that

does not take care of the patients’ physical needs results in

their becoming frustrated and angry and feeling isolated

(6, 12, 18).

Consequences of emotional distance for nurses. Nurses’ reac-

tions to patients they regard as difficult have consequences

not only for the patients but also for nurses’ families:

research has shown that nurses caring for difficult patients

react by being aggressive to their own families (6). The

findings in this article show that the avoidance strategy

carries with it an increased risk of the nurse becoming

emotionally fossilized. Seen from the perspectives of nur-

ses’ ideals for nursing one would expect nurses to be able

to distinguish themselves from their job, like the group of

flight attendants who knew when they were acting and

when not. In the participant observations there are

examples of nurses reacting in a way in which it appears

that they are no longer able to clearly distinguish between

themselves and the role. For example, a situation was

observed where a nurse did not seem to be emotionally in

contact with a patient, even though, before visiting the

patient, she described herself as having such contact. Pre-

cisely in this context the emotional distance becomes

interesting. Where the above-mentioned flight attendants

clearly decided when they were acting or not acting, the

emotional distance of the nurse in this case could be

interpreted as estrangement from her feelings.

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Emotional distance to ‘difficult’ patients 95

Emotional distance may be perceived as an appropriate

way of dealing with the demands of, e.g., nursing, because

it acts as a defence against becoming overloaded by work.

As one nurse described it, she was conscious of an emo-

tional distance to the patients when she did not possess the

resources to address their problems. Emotional distance

may also be seen as an inappropriate defence, because the

nurses obviously do not experience any relief of the situ-

ation. Some of the nurses stated in the interviews that the

emotional distance meant that they were afraid of not

recognizing important aspects of the patients’ needs, and

some expressed the fear of becoming emotionally

detached. Constantly facing situations that a person cannot

deal with can create stress, which may cause illness (27).

Some of the nurses out of the initial 12 selected ones for

participant observations suffered from serious illnesses,

e.g., cancer and heart disease, but this was not character-

istic for the five interviewed nurses of the present study.

Working conditions are often in contrast to the flexibility

and spontaneity which is a prerequisite for emotional

labour, e.g. constant restructuring in the home nursing

unit can make it difficult to perform emotional labour.

Working conditions seem to contribute to create difficulty

in the nurse-patient encounter (28). There was a gulf be-

tween home nurses’ ideals and the possibilities for realizing

them. This disparity carries with it the risk of the nurse

losing control of or access to her feelings, which in turn can

lead to burnout, described as a personal consequence for

professionals working with emotional labour (29). How-

ever the selected nurses for the present study did not seem

to suffer from burnout.

Possibilities in the compromise strategy. Emotional distance

does not have to be the terminal stage. The present study

shows that, where communication is possible to some

degree, this can change into the compromise strategy. This

strategy may be perceived of as an expression of the

patient’s power, as well as of the nurse giving up trying to

keep the patient in the role of a patient. Thus it has

potential in caring for patients perceived as difficult be-

cause it is characterized by the nurse showing a certain

tolerance, a positive attitude and flexibility. It opens up for

dialogue and thereby gives the possibility for perceptions to

be changed, as has recently been found in the context of

physiotherapy (30). According to Travelbee, the human-

to-human relationship model is not possible without

sympathy, and it is not possible to have sympathy and at

the same time to keep a distance to a particular patient.

Furthermore communication is not possible if sympathy

does not lead to mutual understanding (20). Perhaps it

should be accepted in nursing that mutual understanding

is not always possible, and that different levels of sympathy

exist. Travelbee defines communication as ‘a process

which can enable the nurse to establish a human-to-

human relationship and thereby fulfil the purpose of

nursing, namely, to assist individuals and families to

prevent and to cope with the experience of illness and

suffering and, if necessary, to assist them to find meaning

in these experiences’ (20: 123). One may ask whether

Travelbee’s definition of communication is somewhat one-

sided, in that it is the nurse who establishes the relation-

ship, but what about the patient? Travelbee’s idea about

dissolving the nurse-patient roles (to establish the human-

to-human relationship) is interesting but it does not seem

to take into account the inherently asymmetric power

relation between nurse and patient.

Further research and implications for practise

It would be valuable to carry out research focused on

‘successful communication’, as experienced by the patient

as well as by the nurse. Working conditions must be

improved, and it would be useful to discuss the above-

mentioned power relations as well as different attitudes to

and goals in nursing. According to Travelbee, it is not

possible to simulate sympathy even with the most ad-

vanced communication techniques. However one step

would be to dare to admit the negative feelings, talk about

them, react on them, and ask another colleague to com-

municate with the patient. Different strategies to develop

the interaction are suggested in the nursing literature e.g.:

‘Therapeutic communication’, ‘Scenario-based learning’

and ‘Supervision’ (13, 31, 32). There are many ways in

which nurses could be motivated to focus on the so-called

difficult patient’s story, which can be seen as especially

interesting and challenging because it could pinpoint areas

on which professionals should focus to a greater degree.

Conclusion

Three types of strategies adopted by home nurses in rela-

tion to patients they found difficult were identified: per-

suasion, compromise, and avoidance (emotional distance).

The strategies characterized both behavioural and emo-

tional reactions to the patient. Interestingly, avoidance did

not necessarily represent the terminal stage, since a nurse

could revert to compromise with possibilities for dialogue.

With respect to avoidance, this resulted in important social

and health problems of some patients being overlooked.

Other consequences of this strategy were a concentration

on the physical treatment of the illness, and lack of interest

in the patient’s view. Some nurses expressed fear of losing

control of their emotional lives.

Acknowledgements

The author wishes to thank the patients and home nurses

who participated in this study. A special word of thanks is

due to Professor Liora Bresler, University of Illinois at

Urbana-Champaign (UIUC).

� 2011 The Author Scandinavian Journal of Caring Sciences � 2011 Nordic College of Caring Science

96 J.J. Michaelsen

Funding

This study was funded by the Danish National Health

Research Foundation (ref.nr:12-0579-1 kg/mp) and by the

Danish Research Academy (J.nr:V910202).

Ethical approval

Ethical approval was obtained from The Bioethics Com-

mittees for the Capital Region of Denmark (reference

number: KA 91242, KWK/bt).

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