The choice of my topic arose from the observation that there were some patients that nurses labelled as 'difficult' and it was surmised that those so labelled might receive a lesser quality of nursing care than others, and this difference might be measurable.
Two major problems became immediately apparent. Most nurses could identify someone when asked if they had ever looked after a 'difficult patient', but in public and in the present they denied that such existed. They also denied any implied suggestion that they do anything but treat all patients the same.
The other problem was that there was no concept of 'difficult' person in psychological or sociological theory.
Therefore the 'difficult' patient became termed the 'unpopular' patient, and this had the added benefit that it should be possible to identify 'popular' patients and would provide comparisons for any differences in the quality of nursing care they received.
The first part of the study was to determine whether there were popular and unpopular patients in medical and surgical wards and a rating scale and a ranking scale were devised and tested. Both were effective in identifying popular and unpopular patients, but the ranking scale was used because nurses could indicate their reasons for selecting their most and least popular patients and these contributed to a factor analysis of their attitudes towards patients.
While the popularity scales were being developed data was collected from the patients for a factor analysis, to test whether there were any factors that might account for unpopularity. There was a slight significance for a few of the factors but on the whole it was accepted that 'there were no factors other than the patients' personality to account for their being unpopular with the nursing team'.
Information was also collected from the nurses about their reasons for choosing their highest ranked and lowest ranked patients. A content analysis was carried out on the responses and only 9.6% of responses were unrelated to personality factors. (The factors are detailed in Appendix 2.)
At this stage, in order to meet the requirements of the study, it became necessary to identify whether there might be any difference in the quality of care given to popular and unpopular patients, because nurses were so certain that they treated all patients equally well. It was decided to undertake a comparative analysis using non-participant observation in one geriatric and three medical wards.
Popular and unpopular patients were identified in all the wards and discriminatory rewarding and deterrent nursing behaviours were observed and these are detailed in Part II of the study.