How to Care for the "Difficult" Patient

How to care for the "difficult" patient and the tools needed to communicate with compassion.

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How to Care for the "Difficult" Patient

You recently started your first job right out of nursing school. It's your third shift in a row, and you walk onto your unit to collect your assignment. Soon you see your colleagues give you a big friendly smile. Everyone knows you are about to have an eventful evening.

What is a "Difficult" Patient

First, it is essential to understand that the clinician's attitude plays a vital role in patient interactions. In instances where clinical staff are fatigued, angry, and overwhelmed, negative patient interactions are bound to occur. Types of "difficult" patients can include one or more of the following1:

The manipulative patient

Initially, a patient may present manipulative, though their request may not be unreasonable. Examples of manipulative behavior include threatening legal action, suicide, or becoming aggressive and violent to get what they want. Understanding the difference between manipulative behaviors and personality disorders may also be challenging. As professionals, we should make sure that we are aware of our own emotions, be able to set boundaries, know when to say "no," and try to understand what this patient truly needs.

The "frequent flyer"

Patients may come to the hospital often; they will know all nursing staff on a first-name basis and their work schedules. While "frequent flyer" can be a derogatory term to some, it is a well-known patient descriptor. As caregivers, we must understand what leads to increased hospital visits and how we can help. Is it due to a chronic illness, loneliness, lack of social support, or persistent symptoms that are going undiagnosed? We must care for these patients empathetically, as they may need reassurance, education, or more extensive professional support.

The combative patient

Patients will be so terrified and worried for their health that they will express their fear through anger and violence. In turn, this may lead to threats toward staff. To decrease tension, nursing staff should remain empathetic and understanding of the individual. Phrases such as "I can understand how you might feel this way" may reduce patient resistance toward clinical staff.

Patients with somatic symptoms

This may be the most "difficult" type of patient. We do NOT want to assume a patient's distressing symptoms are due to a somatic symptom disorder2. As nurses, we MUST use our clinical judgment regarding patient complaints. Somatic symptoms can include pain, weakness, fatigue, or even shortness of breath. Symptoms can be overwhelming both emotionally and physically. Ultimately patients can have difficulty functioning if symptoms continue to worsen.

Tools Needed to Communicate with Compassion

Unfortunately, there will always be poor patient encounters. The only power we have as nurses are the tools and resources available to either de-escalate or help resolve the issue3. Of course, this may be easier said than done. Making our own mental and physical health a priority can lessen the negative experiences between clinicians and patients. Below are helpful tools nurses can use when working with a "difficult patient."

Prepare for interaction in advance

You know you're about to enter a patient's room with a history of violence and aggression toward staff members. How do you interact with this patient and continue to provide quality care? Try to learn and understand patient triggers. Have patients participate in the decision process of their treatment plan. Using simple terms and avoiding complex medical jargon may also help prevent confusion or misunderstandings.

Active listening

Patients may not feel heard during their hospital stay, especially if they struggle to understand a new diagnosis. Also, staff may be keeping interactions short to avoid conflict. Taking a few extra minutes to listen to patients' fears and concerns may help the treatment team develop possible solutions and treatment options to ease patient fears.

Communicate with compassion

Communication skills are vital in communicating with the "difficult" patient. Strong communication skills include active listening, nonverbal communication, confidence, emotional intelligence, respect, and empathy. When talking with the patient, it may help to remain seated. This can demonstrate to the patient that the clinical staff is taking their time and genuinely listening to what they need. Furthermore, statements like, "I can imagine how frustrating that must be." can demonstrate signs of empathy. Patient encounters can result in positive interactions with the use of strong verbal AND nonverbal communication skills.

Yes, it would be ideal not to have "difficult" patients. However, perfecting the skills needed to de-escalate or ease a situation is valuable in our everyday lives. The ability to read and empathize with others will lead to personal AND professional success.

References/Resources

1The patient from hell: 4 types of difficult patients and how to manage them: MDLinx

2Somatic symptom disorder: May Clinic

3Top tips to deal with challenging situations: doctor–patient interactions: National Center for Biotechnology Information (NCBI)

How to Manage Difficult Patient Encounters: American Academy of Family Physicians

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Vanessa Waits BC

About Vanessa Waits BC, BSN, RN

Experienced nurse with a history of working in the mental health care industry. Board Certified in Psychiatric Mental Health Nursing. Skilled in Inpatient Care, Utilization Review, and Care Management. Professional with a Bachelor of Science in Nursing and a Bachelor of Science in Psychology.

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Specializes in nursing ethics.

Name some more manipulative actions. Are these examples opinion?  What about patients who are choosy who assists with a procedure? Or picky about little issues

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Specializes in Medsurg.

Great advice. I would like to add that nurses are not punching bags so If in a situation with a disrespectful patient, tell them "when you want to talk to me with respect, call me" then simply walk away. 

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Specializes in Psych, Addictions, SOL (Student of Life).

One thing that's missing is setting firm boundaries and don't back down.  Also the first paragraph implies that the other nurses are in cahoots with eachother to give this difficult patient to a new nurse. If that's the case in this hypothetical situation then "Shame on Them." 

Hppy

 

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Specializes in Critical Care.
hppygr8ful said:

One thing that's missing is setting firm boundaries and don't back down.  Also the first paragraph implies that the other nurses are in cahoots with eachother to give this difficult patient to a new nurse. If that's the case in this hypothetical situatipon then "Shame on Them." 

Hppy

 

How do you communicate those firm boundaries to patient family members who are very difficult?

I recently started at an outpatient IR place. I can listen and I am an empathic human by nature... I feel like sometimes I need "go to phrases" to communicate boundaries especially when a family member is shouting, cursing, threatening, finger pointing, causing disruption, interrupting, displaying attention seeking behaviors, or blaming me for things I didn't even do.

What do you say when a patient family member is taking out their rage out on the world on to you? 

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Specializes in ER.

"I'll come back when you xxx"   calm down, stop swearing, are willing to answer my questions, 

"That's not a part or my job" or "that's not a service we offer" if they are asking you to do something extra or harmful. Remember that other nurses can have a minute to do something, but that doesn't make what they did part of the job for you.

"I'll check with my charge nurse" when you need another opinion, or back up for some decision you made. 

Or just say "I'll be back." you might need a minute to breathe.

"I need to take care of medical needs for all my patients before I do the nice extras" they won't care, but its a valid reason to say no.

When the family wants ice, and a blanket, and a pillow, when I'm doing my assessment I tell them I will get it the next time I go out. When I leave I say "You wanted ice, a blanket, and a pillow, and is there anything else while I'm getting things?" Then when I return and they want more I say I'll bring it next time I come in. Rinse, repeat. If the visitors want something, I'm not shy about sending them for a walk to the gift shop or cafeteria. I'll get them water, maybe, but orders for soda and crackers, nope. 

Sometimes people just need to yell, they are stressed and they let it go. Just stand there and listen until they start to wind down. Then reflect their feelings, and add anything you've thought of that might solve one of their issues. If they keep escalating, stand your ground, keep nodding and listening, while your coworkers call security. No reflecting or negotiating when they are being abusive. Call a time out if you can "I think we both might need a minute to think" Make your exit, and call someone that makes more money than you to deal with them.

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Specializes in Psych, Addictions, SOL (Student of Life).
canoehead said:

"that's not a service we offer"

I had a psych patient tell me to go perform a rather intimate act on myself. It's never good to goad a psych patient but wish I could have said this."

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Specializes in ER.
hppygr8ful said:

I had a psych patient tell me to go perform a rather intimate act on myself. It's never good to goad a psych patient but wish I could have said this."

You bust me up!

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Specializes in Psych, Addictions, SOL (Student of Life).

I may have said this before but I usually just kill them with kindness. One of my instructors once told me that on any given day you wil be careing for patients and families who are under tremendous stress. I also am really good at setting boundaries.

Hppy

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