The ability to form trusting, secure relationships or ‘attachments’ across the life course is thought to be influenced by patterns of early childhood relationships. According to attachment theory (Bowlby [27], [28], [30], [31]), a person's attachment style develops from their caregivers’ responses to their early physical and emotional needs (e.g. for comfort and security). That is, the way in which a person has experienced care within significant past attachment relationships influences how they experience care in current relationships. Attachment can be thought of as a psychological characteristic whereby these early experiences of care are internalized as working models (Bowlby [27]). Working models are essentially templates of expectations of self and others, and these templates shape how someone responds in the here and now (Bowlby [28], [29]). As such, they become particularly evident during times of stress or perceived threat (Mikulincer and Shaver [184]).

Broadly speaking, two types of attachment style are typically described: secure and insecure. Insecure attachments have been further divided into the sub‐categories of ‘avoidant’ or ‘ambivalent’ following the research of Ainsworth (see Ainsworth and Bell [5]), who collaborated with Bowlby. More recently, a fourth ‘disorganized’ style of attachment has been described (Main and Solomon [165]).

Where there has been a consistent pattern of availability and responsiveness to needs in early childhood, a secure attachment is likely to form, whereby someone sees themselves as deserving of support and holds a sufficient level of trust in others to deliver the necessary care. Although stressful experiences are still challenging, they do not evoke high levels of anxiety or patterns of avoidance, or they may be shorter lived and the person can reassure themselves during these stressful times. This is because the experience of consistent care that meets our needs is thought to play a significant role in the development of empathy and compassion, including self‐compassion (Gilbert [106]).

When early needs for care have not been responded to, or where caregiving has been unpredictable, then an insecure attachment style can develop, either as avoidance or anxiety (Favez et al. [99]). Here, a person may view themselves as unworthy of support, and may view others as untrustworthy, uncaring or unavailable (Harding et al. [119]). For these people, during stressful events the desire or need for care may feel overwhelming. Some individuals may adopt ways of behaving that give some short‐term relief from this distress, for example avoiding difficult situations (such as hospital appointments) rather than being present in situations that invoke a sense of vulnerability (Mikulincer and Shaver [183]). Alternatively, some individuals may employ care‐seeking behaviours to allay the anxiety that care might stop or be withdrawn, or to elicit reassurance from caregivers where there is little capacity on the part of the individual to soothe themselves or regulate their emotions (Mikulincer and Shaver [183]).

Attachment styles therefore direct the way in which a person can process information, can manage or regulate their emotional states, and can seek or accept help from others. As such, they can exert an influence upon mental health, wellbeing and functioning (Stevenson et al. [259]).

It is important to note that during times of low stress, it may be difficult to identify a person's attachment style. This is because attachment styles most often come to light when we experience stressful life events. In the context of the diagnosis and management of illness, which is arguably a time of stress in which comfort and support are needed, anxious or avoidant attachment styles may become apparent. These can manifest as a patient being easily overwhelmed, having difficulties processing information or adhering to treatment, or experiencing problematic interactions between themselves and their healthcare providers. For example, research among women with breast cancer has highlighted the importance of the nurse–patient relationship, in that a sense of security and trust within the relationship affords the opportunity for fears to be raised and discussed and reassurance sought (Harding et al. [119]). The research found that women's expectations of the nursing staff involved in their care correlated with their attachment styles such that patients with secure attachment styles reported feeling more supported by nurses than patients with anxious or avoidant attachment styles.

It is important for a nurse to hold in mind how a patient's attachment style might influence their perception of care so that the nurse can adapt their own behaviour (as appropriate) to provide patient‐centred support. However, Harding et al. ([119]) note that an avoidant attachment style can be hard to identify and can be misinterpreted as seemingly unproblematic coping. Some patients who appear able to support themselves ask few questions and do not express emotion in nurse–patient encounters, but they may be doing so because their underlying attachment style incorporates a working model of the self as unworthy of support. Similarly, patients with a working model of others as untrustworthy may express anger or may not attend appointments. These behaviours can be misinterpreted as hostility rather than fear, or as self‐sufficient or forgetful (Harding et al. [119]).

In Western culture it is common for people to refer to some thoughts and emotions as ‘good’ or ‘positive’ and to others as ‘bad’, ‘negative’ or ‘problematic’. According to some psychotherapists (e.g. Harris [121]), when faced with problems, people tend to use one of two simple problem‐solving approaches: fix or avoid. Fixing and avoiding work with ‘real‐world’ problems, such as a flat bike tire: the solutions are to pump up the tyre, repair or change the tire, or avoid riding the bike. Naturally, people apply the fix–avoid approach to their ‘problematic’ thoughts and emotions, and as this can be successful in the short term they continue with this approach. However, regardless of how hard and creatively people try to fix or avoid thoughts and emotions, at some point they return. This is because thoughts and emotions do not follow the same rules as bike tires; instead, they are more like the weather – that is, they flux and change and are (predominantly) outside human control.

Therefore, it can be helpful for people to enhance their ability to:

This approach to coping with our internal, private world is embodied in what are known as third‐wave cognitive–behavioural therapies, such as ACT (acceptance and commitment therapy) (Hayes et al. [123]) and compassion‐focused therapy (Gilbert [105]). These have had significant success in helping people to cope with physical health problems, for example chronic pain (Dahl and Lundgren [55]).

When someone is diagnosed with a serious illness, it is natural for them to experience a range of challenging thoughts and feelings, and many of these will be uncomfortable, such as worries and fear that their life is going to change or that they will die. Although these emotions can be difficult, they serve a purpose – that is, they help people to understand what is important and orientate their own and other people's behaviour (Ekman [90]) (Box 5.8). Thus, rather than pushing away these difficult thoughts and emotions, it can be helpful for people (including nurses) to pay attention to them.

Traditionally, family networks (or ‘systems’) are seen as composed of blood relatives and those related by marriage: husbands and wives, children, brothers, sisters, grandparents, aunts, uncles and cousins. In the UK today, however, it is widely accepted that the concept of ‘family’ extends beyond this traditional view. Same‐sex unions are legally recognized. Children may be fostered or adopted, or may live with single parents or step‐parents. They may have step‐siblings. Migration to, from and within the UK means that biological relatives may scarcely know each other. People may feel far closer to friends or other members of their communities. Moreover, today's families may be composed of people from different cultures, religions, class groups and sexualities (Burnham [40]).

Considering patients within the context of their family systems (Figure 5.9) and wider networks can provide nurses with valuable insight into what is important to the patient, their responses to their circumstances (such as illness), and the challenges arising from these responses. Awareness of the systemic context can provide clues about the strengths that the patient and other members of their system can draw upon to help them face difficulties.

Illness affects the patient and their family system. A person's response to the news that they are ill will have an impact upon how others in their system react to the news. Likewise, how family members respond affects the patient and how they behave. For example, a mother's fear about her diagnosis and treatment may frighten her children, and seeing their worry may reinforce her fear (Figure 5.10). On the other hand, the mother's decision to hide her fear may convey that there is nothing to worry about, and she may not receive the care and support she needs.

How people respond to illness often depends upon the various roles they play in relation to other members of their family. For example, one person may inhabit the roles of father, son, brother‐in‐law, uncle and nephew all at once (Byng‐Hall [41]). Each of these roles comes with specific privileges and responsibilities in regard to other members of the system. Simplistically, children are cared for, parents provide care; children obey, parents command. A young parent may occupy both positions, because they are more powerful than and responsible for their children, while remaining the child of their own parents.

Problems can arise when people within the system perceive situations or challenges too differently from each other – for example, when one person perceives a problem when another person does not. For example, a husband may worry about his spouse's ‘drinking’, which they see as ‘just three small glasses of wine with dinner’. Problems can also arise when there is a mismatch in solutions proposed by various members of the system. For example, tensions may arise when a parent cannot bear to lose their terminally ill son, while he can no longer endure the side‐effects of his treatment. The son may feel that his parents’ preferred solution is worse than the original illness, and he may prioritize quality rather than quantity of life. Social roles within people's wider networks (e.g. employee, boss, neighbour, citizen) can also be relevant to a person's response and means of coping with illness. These different roles often come with different priorities; any working parent who has had to leave work early to collect a sick child from school has experienced this.

Moreover, families, like individuals, can be seen to have life cycles (Carter and Goldrick [43]). As a family transitions from one stage to the next, the established roles and expectations that members have of each other change. Power dynamics eventually become reversed. The overlap of social and family systems during a transition can be seen when a parent retires. They lose the social status associated with their professional role and may become increasingly dependent upon their children.

Serious illness can also upset the power balance, and expected order of life cycles, within the family. A previously autonomous person may be forced to adopt the ‘sick role’ and self‐identify as a patient, needing assistance with deeply personal and intimate functions. In receiving care, past as well as current roles may influence a patient's relationship with help (Reder and Fredman [238]), depending upon the beliefs they hold about how to behave within their various roles in relation to the others in their multiple systems. This affects how the patient sees themselves in relation to the doctors, nurses and other healthcare professionals involved in their care.

Families are also systems in which attachment relationships (see above) begin and attachment styles develop. While attachment style can be a key factor underpinning a patient's relationship with help, ‘family scripts’ (Byng‐Hall [41]) may also be relevant. For instance, if independence and self‐reliance are over‐valued within a family's culture, asking for and accepting help can become difficult and suddenly finding oneself in a position of dependence can be extremely uncomfortable. Alternatively, if a family's culture fosters dependence upon a single member, it can be difficult for anyone else to develop belief in their own ability to effectively meet the challenges life presents. Such persons might be at higher risk of becoming overly reliant upon professionals to make decisions for them and manage their care.

Hospitals, and the treating teams that comprise them, are systems in their own right as well as forming part of the wider network of systems around the patient and their family. As such, it is important to consider interactions not only between patients and individual clinicians but also between the patient and the organization, whether at the level of the team or the whole hospital. Communication and interaction between the individual and the organization will be affected by the roles adopted (such as patient versus professional/expert, or consumer versus service provider) and by the dynamics generated when these roles are assumed.

In the same way that nurses are all members of their own family systems, as workers they are also members of organizational systems. They are affected by the organization's policies, priorities, investment decisions and other aspects. As Reder and Fredman ([238]) point out, in addition to being guided by their own personal and family beliefs about receiving and providing assistance and care, nurses must be consistent with professional and service contexts, including statutory obligations as well as ethical ones. Professional contexts come with assumptions regarding roles, duties, responsibilities and rights. At times, these assumptions may clash with those held by patients and their families, as well as those held by colleagues from other professions.

As more teams and services become involved in a patient's care, complexity increases further still. There may be power differences between teams, and the patient's relationships with the various teams may reflect those differences or be impacted by them. Moreover, other systems are commonly involved in complex patient care. These might include education, local authorities and the justice system, all of which can work simultaneously and in conjunction with each other, as illustrated in Figure 5.11.