Difficult Patient - Definition

HouTx, BSN, MSN, EdD · Oct 1, 2015

What about # of patient/family requests per shift? If you have a good call light system, that data is retrievable. Other factors could be related to care needs such as #meds, complex interventions, #mobility needs, etc.

AcuteHD · Oct 1, 2015

I wouldn't consider BMI to be an issue unless they are known to be immobile as well.

ixchel · Oct 1, 2015

Quite a heavy first post, OP.

I disagree with the attempt to standardize this. Let's face it - every single patient has varying degrees of ability and disability, which is rarely dependent on diagnosis, BMI, or any other cookie cutter you aim to use.

In my opinion, if the primary nurse labels a patient "difficult", then they are difficult. Maybe my unit is a rare gem, but everyone I work with is mature and professional when difficult patients are in their group. It's rare anyone asks to have a patient be reassigned.

Additionally, what is difficult to you may not be difficult to me. I had a total care, mostly non-verbal and incontinent woman at the end stages of dementia. During my time with her, she lost ability to swallow and the decision to not get a PEG tube was just made. She was a technically easy patient. Only meds were some q6h and q12h abx. She was very low maintenance and was incapable of asking for a single thing.

She required frequent clean ups, which she hollered during. She was in pain because her perineum and buttocks were excoriated. She had become a ward of the state recently because she had no surviving family members capable of providing her the care she needs.

My grandmother was just diagnosed with Alzheimer's almost 2 years ago. I hope to god her body fails her before her central nervous system does. I couldn't help it, no matter how hard I tried - counter transference was an absolute beast when I had that patient. After the second day, I asked if she could be reassigned. To me, she was a difficult patient.

Obviously you'll have the more obvious types of difficult - the violent ones, the demanding ones, the mean ones. We have one frequent visitor who is absolutely hateful to most of the staff. I shared him with one other nurse for a three day stretch and he was the sweetest person to both of us. We treated him with dignity and didn't let his initial grouchiness turn my mood sour. We respected his space. Everyone else would call him difficult. Us? We looked forward to seeing him.

It's all completely relative.

AcuteHD · Oct 1, 2015

Double like

AmyRN303, BSN, RN · Oct 2, 2015

Sometimes the most technically "easy" patient is actually the most "share the love with others" patient, as Ixchel said. I've often had that situation happen. I don't think there's any standardization possible, though I agree that sometimes, you need a break.

whichone'spink, BSN, RN · Oct 2, 2015

I had a higher tolerance for frequently incontinent, turn every 2 hour, type of patients. What I would often request reassignments after 1-2 shifts with patient would be the emotional vampires. The ones that suck you dry, try your patience, and wish you never became a nurse.

Anna Flaxis, BSN, RN · Oct 2, 2015

As other posters have pointed out, what makes a patient "difficult" is totally subjective, and I think that's okay. We are all human, and what might be difficult for me to deal with might not be an issue for you, and vice versa.

I work in the ER, so we don't have the same assignments from day to day, but we have a few repeat customers that can be taxing to deal with, so if I took care of them last time, I have no qualms about asking one of my co-workers to take care of them this time. Or, if my co-worker will answer the call bell this time, I'll medicate/get vitals/start an IV/etc. on one of my co-worker's patients.

jadelpn, LPN, EMT-B · Oct 2, 2015

Work the staff according to strengths. Do a little email blast "what is your favorite kind of patient" and you may be shocked at what you see. Part of your assessment could be behavior patterns that are conflicting or a barrier to function. With that needs to be some interventions that are standard, interventions that are specific to the patient, and outcome. In other words, part of a nursing care plan that everyone follows regarding behaviors. It is hard otherwise to take subjective information and make it objective.

For me, I LOVE the fringes, I enjoy the thinking that it takes for "difficult", complex, behaviorally challenged patients. I know my resources and how to use them. Cardiac or post op or pre op bore me. Not that I give those kinds of patients less than my best, just isn't my "thing".

Immobile patients need a pairing of CNA's. OR a strong CNA to be with the nurse. Interventions need to be consistent to modify behaviors that are actual barriers. Just because someone's a jerk doesn't mean that they are non-compliant. If the goal is to get them home, then every other discipline needs to be on the same page. PT/OT, social work, case management...

But ask each nurse what they like. You may find one or 2 who relish in the behaviorally challenged, and can work them well. If you find there's a group who is very "no way" then is the time to point out resources, interventions, the "goal" so that there is a tangible end to the admission.

You may also want to rotate CNA's to be bell answer CNA's for the shift.

Best wishes!

madwife2002, BSN, RN · Oct 2, 2015

Moved to patient/nurse relationship forum

betterinthesun · Oct 3, 2015

Like others have mentioned, unfortunately I don't think there's a standardized measurement for how psychologically taxing a patient is. My unit gets a lot of drug/alcohol withdrawal and sometimes we use CIWA/COWS scores to define how difficult that patient is but that only applies to withdrawal patients. For demanding patients, patients with unruly visitors, etc. there just isn't any sort of scale for that. Maybe we can create one! Your best course of action for now would be to make sure the charge nurse, supervisors, etc are well aware of a difficult situation and document appropriately.

Its perfectly understandable to need a break from those types of patients and hopefully those in charge of staffing at your facility agree.

I hope you get some relief from those difficult patients!!

Karou · Oct 3, 2015

Yeah, this is impossible to define objectively because it's completely a subjective thing.

Difficult to you isn't the same as difficult for me. I may be okay with certain types of difficult and not others also.

I think the best thing is to have a supportive environment where it's okay to ask to switch patient assignments/groups. I rarely do this but it's not uncommon in my unit for a nurse or PCT to be exhausted from an assignment and switch the next shift. We call it spreading the love.

We do make sure that too many isolations, total care patients, and baristri can patients aren't assigned to any one person. Never will someone have two trach patients either.

If I am overwhelmed by an emotionally depending or manipulative patient (I would rather have all incontinent total care patients then to many of these psych ones!!!) then I might ask a coworker to trade a task with me the next time that patient called or needed medication. "Hey 34 is ready for his 2mg dilaudid, 25 Benadryl, Xanax, and 12.5 phenergan. If you give it to him for me I will help clean your incontinent c-diff patient in 43 or do your wound care for 46."

We work great as a team on my unit. And there is always lots of love to share and spread :)