1. Shattell, Mona PhD, RN

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When I was conducting research on the hospital environment, a colleague told me about her grandfather, Henry, who made small, hand-carved wooden boxes for nurses when his wife was in the hospital. When he was hospitalized years later, the nurses remembered Henry as the kind man who gave them gifts, and Henry insisted this was why he received excellent care. Sadly, this story was one of many I heard that confirmed my research. Because patients see the hospital environment as dangerous, confining, disconnecting, and even identity stripping, they also feel they have to manipulate the nurses in order to receive high-quality nursing care.


Interviews with patients show that they believe the quality of care they receive depends upon the relationships they establish with nurses, and that they work to make nurses their friends, "be an easy patient," and "try to get them to listen." Some patients reported having a sincere desire to establish a genuine relationship with their nurses, a connection that affirms the patient's unique identity. Others, however, built relationships as a way to get nurses to remember them-in the hope that the nurses would be more responsive to their needs if they "stood out from the crowd."


Nurses are aware of the tactics that patients use to entice them. But, many patients' methods are so subtle they may go unnoticed. Afraid that the nurses wouldn't give her the necessary care, one patient placed a vase of flowers in a conspicuous place to show off the card from her friend, the hospital's CEO. If she didn't see the nurses notice the card, she would try to draw their attention to it by glancing at the flowers, hoping her friend's prominent position at the hospital would make her care seem more important. Sometimes patients are deliberately deceitful. One patient admitted, "You build the relationship differently. . . . With the older [nurses], I would talk about the hospital and what a great hospital it was and even try to word it to produce positive conversation. . . . And then the young ones, I'd just ask them why they majored in nursing and [about] the shortage and [say] that I was encouraging my daughters to do it. Just nonsense, utter nonsense."


Unfortunately, sometimes the patients are right-their care is affected if nurses label them as "easy" or "difficult" patients. After all, nurses are only human. But because patients rely on nurses for their care, it's often up to the nurses to make the hospital a less frightening place. When a nurse reacts badly to a "difficult" patient, it can strengthen the patient's perception of the hospital as a dangerous place, as revealed in one participant's story of a hospitalized friend:

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She was in terrible pain and nobody seemed the least bit concerned about it . . . we had a scene, finally. Her pastor was there and I was there and her doctor was unfortunate enough to come in making rounds, and we both just jumped all over him, that this was inexcusable, and he didn't like us one bit; then the nurses just took it out on Mary because he went back, jumped all over the nurses. . . . Mary said they would hardly speak to her the last two days she was there . . . the worst part was when they hated her; she just couldn't wait to get out.


As a nurse, I'm uncomfortable with these findings. I don't want to believe that nurses give lesser care to patients who complain, who are difficult, or who do nothing to entice nurses. I don't want to believe that patients assume that in order to get high-quality care they have to live by the adage espoused by my colleague Lana: You catch more flies with honey than you do with vinegar. Unfortunately, what I want to admit or believe is not important. The words of my research participants make it clear what they believe.