This is my very first blog and musing! I hope if you read this you are indulgent with me and add some comments at the end so I can use them to reflect and learn!
This first blog is a story that starts with a trip to the dentist. I have been having trouble with a tooth for a while. My brother-in-law is my dentist: ‘I think we need to take it out, Anne’ he says. Now, let’s just put this in context, it’s a big tooth, a daddy one. I’ve never had a tooth out before; only those that I wobbled out as a youngster. ‘OK’, say I, meekly (my heart started to pound – OMG thinks I).
The next part isn’t pretty. I sat in the chair while he wrested the tooth out. I didn’t like it, not one bit. When he was done he came and looked at me, properly looked, and then gave me an unexpected hug. My feelings must have shown in my face.
‘I’ve been a good patient, haven’t I?’ I asked.
I have no idea why that was the most important thing to ask at that time. What on earth did I mean ‘good patient’ and why did I ask?
I started to think about how health was viewed by me and in my family and what was deemed to be important. I’m a northern girl, brought up in a hard community of working class families. Ill health was not part of any discussions I can recall as a child. My thoughts took me back to my granddad. He is dead now but I loved him very much. He was a little hardy man who I know loved me unreservedly. Later on in his life he had chronic obstructive pulmonary disease. He walked his little dog, Trixie, nearly every single day of the last decade of his life. As his condition got worse he just adjusted the length of the walk and went more slowly. More importantly, I never once heard him complain about his breathing. If he was puffed we would just stop for a few minutes. I suspect what he was demonstrating was ‘being stoic’.
Grandad and Trixie 1979
So what is being ‘stoic’ and does it/should it matter to those providing care?
I decided to have a look at nursing literature and explore whether behaviours such as stoicism were considered, when we are looking after patients. There wasn’t extensive literature but I found one very interesting paper by Spiers (2006). Spiers (2006) links stoicism to a determination to endure and also comments that endurance allows the patient to remain in control; patients can present ‘themselves as a stoic person who was able and willing to tolerate pain’ (p. 296).
This presents a dilemma for nurses, the need for patients to remain in control and yet support them in dealing with issues where they may be close to their edge of tolerance. I would argue that in these circumstances nurses need sophisticated communication and assessment skills that allow patients to express stoicism at the same time as dealing with complex symptoms such as pain. These are difficult skills to teach and learn. Spiers (2006) cites some interesting examples of the interactions between nurses and patents.
So it appears that not all patients are the same, no surprise there then, and that nurses need to have complex communication skills to deal with patients like me who have a desire to remain stoic and in control. I’m not sure these are conversations we have often enough as the ‘do you have any pain today, Mrs. Cooper’ may not work for me and I hope in future if I need nursing care I have a nurse who can think beyond a pain assessment scale.
Thank goodness my brother-in-law (aka Dentist) had good enough skills to assess that I was feeling a bit grim – a hug that day went a long, long way!
Spiers, J., (2006) ‘Expressing and responding to pain and stoicism in home-care nurse-patient interactions’ Scandinavian Journal of Caring 20 pp 293-301 Abstract available online http://www.ncbi.nlm.nih.gov/pubmed/16922983
anniecoops 
Dear Annie,
This is a thought provoking start to blogging, and worth the read. I agree nurses need a range of sophisticated skills for establishing a positive working relationship with the patient. It’s is the practical exposition and acquisition of these skills that seems to pose a challenge now. Does social media use help or hinder this? You say the practical result of one person noticing the distress of another will give rise to an opportunity to offer comfort; its having the eye to spot the opportunity and courage to act that make the difference.
What a lovely post! Welcome to blogging!
When I was reading your post it also struck me that your post was about professional boundaries. What if your dentist wasn’t your brother-in-law, but someone who just had a dentist-patient relationship with, then how would you have felt about the hug? Was your brother-in-law really using professional skills to assess your need for a hug, or was it more to do with the fact that he has known you for a very long time and that you were feeling (rightly) put out by all that had happened.
To expect someone who doesn’t have that degree of relationship with you to be able to reach the same understanding might be a wee bit tough?
Thanks for writing! Long may it continue:)
Great stuff Annie. Strikes me that this is about shared decision making and understanding the values and preferences of your patient. In three years in this health world I have not heard anyone talk about stoicism but it reminds me of the debates about supported self management. I think patients wrestle with the contradictory impulses of wanting to be in control and wanting to be looked after and to cede control. How we make the trade off depends on who we are and the state of our condition. I agree it needs sophisticated skills and judgement on the part of the clinician to understand the dynamic and work with it. Get it wrong and you are either taking over and infantilising your patient, or denying them care when they need it.
Anne-Marie: Thats a really interesting observation and perhap, Yes, he does know me very well. What I was more interested in exploring, though, was my feeling of needing to be a ‘good’patient’. I clearly felt the need to continue to at least look like I was in control and not in any way flapped by what had happened! I was very ‘flapped’ indeed!
The episode was merely a trigger that led me to a reflection. I hadn’t thought about my little granddad (he was only about 5 feet tall) walking that dog, when he could barely breathe, for a while. He was definately a stoic man. I will never now know why that was. It led me to conclude that if we are task oriented as carers and focus solely on the pathway of care, for example just rating a patients pain on a scale, we might miss these subtle signs from patients. This is, for me, what nursing is all about and we need the skills to deliver patient driven care. I say driven deliberately.
Thank you so much for commenting.
Jeremy: Thank you so much for commenting. I completely agree with what you say. Its challenging to provide care at this sophisticated level in a world where we are often taught to focus on pathways, processes and tasks. The role of a nurse is indeed a difficult one and I hope (for my sake!!) that we are able to continue recruit and develop nurses to deliver care at this level.
What a great blog Anne! It made me reflect on the stoicism of care professionals and how that can also be a barrier to great communication with our patients. What is the boundary between remaining professional and showing human compassion and yes, sometimes sharing the distress of the people we come in to contact with. As a mental health nurse, this was often something I thought about, especially when listening to some really dreadful experiences of some people and the impact it was having on them. It was sometimes hard to keep a dry eye. If they saw my distresss would the be a barrier or aide to building trust with them? Such a fascinating area.
Mandy: Thanks for commenting – great thoughts – yes of course as carers we too may be stoic and as you say this could create a barrier to care delivery. Perhaps we might come over as a bit ‘cold’ or ‘distant’ but then the alternative could be equally difficult – patients like me really don’t want our nurses weeping all over us 😉 – delivering care to take account of complex relationships is a quality indictaor for me but no idea how you would measure it!
Anne
Thank you for sharing – the stoic approach and desire to be a ‘good patient’ are both interests and important. Less experienced nurses may underestimate the desire for older adults (not yourself obviously) to be the good patient even in times of pain – this stoic approach can at time lead to distressed behaviours. My mum, in her care home, doesn’t want to ‘bother’ the nurses when she’s in pain – but tells us when we’re there. I think there are times we miss the cues, when others are being stoic. Glad the therapeutic hug helped – given the circumstance (relationship) ’twas entirely appropriate.
Yes, great point about the quality indicator and measuring this. I wonder if it is somehow part of the patient experience feedback we need to be doing and measuring their perception of C for Compassion? We might need to word differently, but what we really want to measure is whether the patient felt the nurse was listening to them, understood, had any kind of empathy, made them feel comfortable with expressing themselves or needs (this covers a multitude of settings & scenario’s, for example, acute, mental health, bereavement, traumatic injury/events etc). Just a starting point that probably needs much more thought…..
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