How to Care for the "Difficult" Patient

Vanessa Waits BC, BSN, RN

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