Developing X-ray Vision: Caring for Difficult Patients

Do you sometimes struggle with taking care of angry, belligerent, difficult patients? This article looks at some practical strategies for pushing through those hard situations with professionalism. Nurses Announcements Archive Article

Developing X-ray Vision: Caring for Difficult Patients

As the EMS transport unit pushed the gurney out,I set my bag down on the empty chair before walking across the nursing home room to the Bob's side. I introduced myself as his hospice nurse and asked if he wanted to talk or if he had any questions for me. "Nope. Just want to smoke. Why won't they get me a cigarette?" I told him we would work on that and gently explained how the staff would help him get outside to smoke. He said he understood, but his expression of anxiety did not ease. "They told me at the hospital that if I came over here, they would let me smoke."

I asked permission to do a brief assessment and reached to take his pulse. I noticed long tattoos on each arm and multiple scars of various lengths. His dyed black hair was thin from an unsuccessful round of chemotherapy. His teeth were decayed and several were missing. After I took his pulse, I gently squeezed his hand and assured him that we would work on getting him outside to smoke as soon as we could get him situated.

I had previously read his discharge summary from a recent hospital stay and had also spent some time with his mother, getting the history and learning the sad turn of events that brought us to this day. Only in his 40's, this man had a terminal diagnosis of lung cancer now widely metastatic to his liver, bones and even brain. He was uncomfortable and angry. And afraid. His mother reported that he would not go to sleep, forcing himself to stay awake as much as he could.

As the weeks moved on, his behavior toward the nursing staff at the facility became difficult. Demanding and loud, he repeatedly pushed the call bell and then seemed to make up needs to keep them coming back. His pain and anxiety medication required constant adjustment, but his biggest and most vocal complaint related to his desire to smoke: a big man, he also had ascites and lower extremity edema along with severe weakness. Getting him outside in a wheelchair was a very time-consuming ordeal.

As hospice nurses coming in for visits and to help with personal care, we did our best to make the situation as good as it could be for our patient while also trying to be understanding about the nursing home staff's needs for support in providing the more intense care that Bob seemed to need. His anger and belligerent behavior had long ago strained to the breaking point his relationships with family and friends. Because he could be hard to be around, and at times verbally abusive, his family's very human tendency was to avoid contact with him or to keep their visits short which, paradoxically, was just the opposite of what he seemed to need.

As nurses, how do we push through these difficult care situations? In our training, we learn strategies on how to listen, how to maintain boundaries, how to be professional even in trying patient encounters. But when challenging patients occupy a lion's share of our time, energy and emotional resources we can find ourselves feeling resentful and maybe even angry.

What are some ways that we can continue to provide excellent and professional care in difficult situations?

First, we can persevere through difficulty by keeping our own bodies and spirits in balance

When we are exhausted, when our own wells of the spirit are dry, we find it hard to pull up a bucket of compassion and care to give to our needy patients. Getting enough rest, exercise, eating a well-balanced diet and maintaining outside interests can help us be at our best. If I had to guess, most of us nurses have a tendency to continue to provide care even when we are weak from hunger, dying to go the bathroom, and bleary-eyed from lack of sleep. It is not an ideal world, for sure, and some days are simply harder than others, but making a conscious effort to address our own physical and spiritual needs can be just the medicine!

We can look beyond the annoying or difficult behavior to see the underlying cause

Bob's situation reminded me again of how easy it is to get bogged down with frustration over how patients act, instead of looking at the root cause. It is hard to say what kind of person he was before the cancer, but with it he clearly became fear-filled. His demanding attitude, verbal abuse, refusal to give in to sleep and even his denial of his own feelings, highlighted that fear. As nurses, when we can step back a bit and ask ourselves, "What is contributing to this difficult behavior?" then we are on our way to developing strategies to address it. Whether it is fear-as in Bob's case- or something else such as a loss of control, unresolved grief from prior life events, unaddressed physical symptoms, looking past the here and now to what might be behind it all can help us be more patient. While fully addressing root causes is often beyond the scope of our immediate care for the patient, thinking about the behavior in new terms can help us find the emotional and physical energy that we need to continue to provide care.

We can work as a team to plan out strategies for helping demanding, difficult patients

This can mean scheduling room checks; planning to stop by his room before the call bell lights up; providing a supportive environment that encourages the family to stay with him; enlisting the help of social workers, chaplains, volunteers or other ancillary staff to cover the times when we simply cannot be present-all of these in concert can help alleviate a difficult situation.
Bob's situation reminded me again of the importance of looking beyond the behavior to find the cause. As professionals, we can all benefit from a different type of vision: focusing on our personal well-being and also looking beyond to superficial to see our patient's motivations and needs with new insight.
Joy Eastridge, RN, BSN, CHPN
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About jeastridge, BSN, RN

(Columnist)

Joy has been a nurse for 35 years, practicing in a variety of settings. Currently, she is a Faith Community Nurse. She enjoys her grandchildren, cooking for crowds and taking long walks.

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Specializes in Peds, Med-Surg, Disaster Nsg, Parish Nsg.

Thanks for this impassioned reminder. Many times we tend to want to avoid these types of patients, forgetting that they are many times facing overwhelming life-changing changing challenges.

It's times like this that we need to try to see life through their eyes.....even if just for a few minutes. But also important is the reminder to take care of ourselves, as these types of interactions can be draining.

The Hospital I worked at would often have patient care conferences,to help problem solve on such patients. This was helpful to staff and the patient, The care conference included the nursing staff, social service dept, and the patients doctor and family.