Angry patient theory

[snowfreeze, BSN, RN]

I seem to notice that the angry patients with angry family members seem to be the sickest ones and many times the more non-compliant ones.

Sometimes you can get them to calm down enough in between their outragous requests and demands to give you a little bit of background.

Most who finally do trust me to chat a bit seem to have an unresolved issue involving themselves or a loved one concerning hospitialization, doctor involvement as PCP or specialist, recent death, something they read recently in the newspaper or online or saw on TV or a significant influencing non relative with a recent medical issue. These are the patients who really need you to care for them but usually have a "family' guard at the doorway making you teach nursing 101 prior to even checking a blood glucose.

These are the patients you can dump gallons of antihypertensives into and their B/P is still at explosion level. Their blood sugars are irratic. Their anticoagulant therapy is off the chart as far as how much you are giving them and their pt/ptt INR are still not therapeutic. Enough pain meds to kill an elephant and they are still writhing in pain.

Is this a post traumatic stress disorder related to anxiety which is self or environmental? Would proper therapy help? What type of therapy and what type of interaction is successful in getting this information in the first place.

I would like a bit of input from nurses dealing with these types of patients/families to help outline some effective ways of properly working with them.

[Selke]

No advice here snowfreeze ... your post really stood out to me. i just want to say that I think you exemplify what best nursing care is about by trying to figure out what lies behind these outbursts, anger, and noncompliance issues with your difficult patients, and addressing that. It seems that you are approaching them the correct way ... not being scared off ... sitting down (as you have time!) and talking to them with open ended questions (I presume) then listening to what they have to say, including the anger, without running, flinching, judging, or cutting them off. Having a chronic illness, losing your physical ability, is a loss and is horrifically painful emotionally and physically. It is like dying. If one has no mental framework or belief system in which to frame such an experience and cope with it, it can be overwhelming. They may need a story (religion or other), a belief system, in which they can fit their story, find hope, and find the means to heal the pain, to take action, no matter how small, to heal their condition. They need to know they are not alone but may fear that dependence. It may surprise the patient that someone actually is sitting through their outbursts and pain, listening ... they may have never experienced that before. You sound like a very wise person.

I'm interested to read what advice you get.

[nyapa, RN]

'm not sure that the angriest are the sickest. Thats a bit like saying, "which came first, the chicken or the egg".

But really, I think its important to use your judgement. Sometimes you can just 'clash' with ppl and it doesn't matter what you do. Or they are usually abusive, have learnt that to get anywhere in life that to yell and attempt to scare ppl is second nature.

That being said, some of the things you raise make sense. Abuse can be attributed to: fears of nurses, staff, environment, or illness; current social circumstances; psychological conditions such as depression; cultural background and families experience with the health system etc. It can also be attributed to plain physical reasons, such as pain, confusion related to health disorders etc.

So I think to try and allay the above its important to try and gauge what it may be related to. But that will only occur if the patient chooses to share it with you. And if the nurse chooses to listen.

1.With the confused, I have found diversion works.

2.Use of a calm demeanor and non threatening posture can help in all these situations.

3.Trying to give this person access to needed services is also important but no more so than other ppl.

4.Just letting them know you are going to do something for them, and then doing what you have promised goes a long way to gaining trust.

That being said, nurses should have a right not to experience verbal or physical abuse

So creating a few boundaries such as, "When you calm down I will come back and talk to you" and letting them know that you don't have to accept abusive behaviour may also be necessary as a last resort.

Finally you may need to involve senior staff.

And document everything when abuse occurs...

[RN1989]

To me these people seem to be the ones who feel trapped in their situation. They are in denial about everything and then complain that it is everyone else's fault that they are in the situation. It's their mother's fault for making them clean their plates so that is why they are fat. It is their husband's fault for bringing desserts into the house when their husband knows that they are diabetic. It is the tobacco company's fault for making them addicted to cigarettes.....and the list goes on. I think these are people who have become so mired in self-pity that they hate their situation, refuse to take responsibility for their own choices and want to make everyone else as miserable as they are. Personally I am sick of people like this. Grow up. You didn't see our ancestors back in the pre-electricity era. moaning and groaning about everything. They would have never gotten their work done. I think it is high time that people take responsibility for their own choices and actions instead of wanting other people to do it for them. No wonder people feel trapped and out of control - they are giving that control away willingly. Hard work never killed anybody but a spiteful heart only makes your body get run down and sick more often.

[Blee O'Myacin, BSN, RN]

I find that anger and stress feed on each other, and that there are people in the world that are simply not nice.

When it is possible, I try to figure out where the anger is coming from and why it is being directed at me. Sometimes there is no other way of doing that except for simply asking the source of the anger. "What is making you angry and why are you directing this at me? I saw a call light on and here I am, answering your call light. Please don't shout or curse at me." The direct approach works if you can manage it. Some people are unaware that their behavior was out of line.

In the ICU, I'd remind family members that they need their rest too and even though we had open visiting hours, they needed to go home to rest and recharge. Their loved one in the bed needed to only think about themselves and sometimes that is hard to do when the patient is too worried about all the other people in the room. I've also noticed that anger goes down in direct proportion to the amount of information they are given. Even if it's a discussion about our heparin protocol or the A&P behind congestive heart failure. Calm discussions that impart information seems to diffuse situations, and it also returns control of the situation to the nurse.

I speak up for myself. If a patient complains about how long it took to get their pain meds (19 minutes from order entry to delivery on a non-urgent patient when I had two criticals in the other beds) - I tell them what held me up. "Sorry about that, in the 19 minutes from when the doctor ordered your percocet until now, I received one ambulance patient who required immediate intervention and another who's cardiac monitor was alarming. The delay was unintentional."

Document everything. It's time consuming, but at least there is a record about the events when it comes time for that family to start naming people in lawsuits. When a pattern of behavior is established, along with attempts to get to the cause, at least no one can be blamed for "doing nothing".

Blee