How do you handle manipulative/demanding patients?

  1. I am a new psych nurse (this is my first nursing job) and I'm having a hard time with what to say to patients with unrealistic requests. I just recently came off orientation, so I don't have my preceptor with me anymore when dealing with difficult patients.

    Recently, I had a patient with intermittent explosive disorder. He was very demanding, threatening to sue me, and promising I would no longer have my job when he was done with me. I didn't feed into these threats and I knew they were unfounded. One request he made at about 2am. He wanted a laxative. I asked when he had his last BM and he said earlier in the morning. On my unit, we don't have standing orders for things like laxatives, Tylenol, etc. Every order has to be either verbal, or by phone. I told him I did not have an order for a laxative and that he could request one when he sees the doctor in the morning, but that I had nothing available to give him right now. He demanded that I call the on call doctor immediately and get him a laxative, and went on and on about how I am causing him physical pain and denying him of his patient rights. I politely pointed out to him that he said he had a BM already that day and that it was not a medical emergency. What I was thinking in my head is that there is no way I'm calling the doctor at 2am for a laxative! We ended up finding him some prune juice.

    My question is, did I do the right thing? How do you experienced nurses handle patients that demand you call the doctor when you know it's not an emergency? Do you just flat out say no? I feel like if I tell patients it is not a medical emergency, then they will fake one to get what they want or become violent. I also wanted to set boundaries with this patient too because he was very manipulative. Just curious as to what other nurses would have done.

    Thank you!
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    About kimmyanne02, RN

    Joined: Nov '14; Posts: 26; Likes: 38

    16 Comments

  3. by   MrChicagoRN
    Quote from kimmyanne02
    What I was thinking in my head is that there is no way I'm calling the doctor at 2am for a laxative! We ended up finding him some prune juice.

    My question is, did I do the right thing? How do you experienced nurses handle patients that demand you call the doctor when you know it's not an emergency? Do you just flat out say no? I feel like if I tell patients it is not a medical emergency, then they will fake one to get what they want or become violent. I also wanted to set boundaries with this patient too because he was very manipulative. Just curious as to what other nurses would have done.
    You did fine.
    Be kind, consistent, and firm. Don't let them put you on the defensive.

    A "sorry, I can't do that, the answer is no" is appropriate. Offering alternatives and diet teaching are also good.
  4. by   RegularNurse
    Saying no is fine on a psych unit. Axis II patients just want to stir the pot. When they know they can't get a reaction out of you, they move onto the next staff member, and eventually, the next facility.
  5. by   Meriwhen
    Quote from kimmyanne02
    I feel like if I tell patients it is not a medical emergency, then they will fake one to get what they want or become violent. I also wanted to set boundaries with this patient too because he was very manipulative. Just curious as to what other nurses would have done.
    And if he gets violent, you call the MD and get an order for a B-52 IM (Haldol 5mg, Benadryl 50mg, Ativan 2mg) or whatever lay-them-out-flat shot of choice your MD prefers, and your patient gets a couple of needles in his gluteus. Then (hopefully) he'll learn that violently acting out wasn't really a good idea after all.

    Agree with the others: boundaries are a must. Acknowledge his frustrations but stick firmly to the boundaries. Be consistent. Every. Time. And there was nothing wrong with finding him prune juice...in fact, that was a good move on your part: you still made the effort to address his needs in the way that you could at that time
  6. by   WinterLilac
    I too like the fact you were firm but also came to a compromise in regards to finding him some prune juice.
    You validated his frustrations about needing a laxative by offering an alternative that did not require other people being disturbed by his demand but also providing him with nursing support. You also covered yourself in case he really was constipated. Even though these people have a history and diagnosis, we can't assume everything they say is attention seeking behaviour, if we did we would soon be back treating people like in the early 1900's.

    I would also suggest you debrief with your colleagues. Ask what they would have done. You may find you'll get different answers but take from them what you feel is beneficent to your patient.
  7. by   kimmyanne02
    Thank you so much everyone for taking the time to reply! I feel like there is such a fine line between being firm and setting boundaries and the patient interpreting that the nurse's don't care. In fact, this was all part of a "riot" one night on the unit. There was one borderline instigating bad behavior in other patients as well as herself. We had to call security multiple times. This patient verbally harassed myself and some other nurses. I have developed a pretty thick skin, but this patient as well as 2 other patients ganged up on me and I had had it. They all started making fun of my appearance and how I am such a horrible nurse. I kept telling myself that they are sick and don't take it personally, but sometimes someone says that one thing that really hurts. I wonder if they are aware of their actions, or if they just don't care. It's hard to continue to provide quality care to a patient who was just verbally abusive. Ahhhh, the joys of psych!
  8. by   WinterLilac
    Eck, ganging up on you and insulting your appearance is verbal abuse, intimidation and bullying and should not be tolerated. I hope those patients were reprimanded firmly for that incident.
  9. by   vintagemother
    Quote from WinterLilac
    Eck, ganging up on you and insulting your appearance is verbal abuse, intimidation and bullying and should not be tolerated. I hope those patients were reprimanded firmly for that incident.
    On the psych unit I worked in, techs were always there to stop a pt from escalating. The techs were especially protective of us nurses.

    As a nurse, I also protected and shielded my techs, as well. It takes a team working together in psych.

    I'M working in an acute medical unit, yet I still come across some agitated pts. We don't have techs to deescalate.

    I basically try to be firm and kind. Compassionate, yet distant emotionally. I.E. I do not engage.

    Yesterday, a pt was acting manipulative, stating s/he wouldn't accept the meds Id already poured in a cup unless I added a strong narc with them. I was, well, pissed. I wanted to tell the pt that s/he could refuse their routine meds and if so, that's fine.

    Instead, I checked myself and carried the meds back to the Pyxis and prepared the narc... Only to realize that the narc wasn't due, as the pt had recvd it 2 hrs earlier! Sigh!!!

    i chose the high road and explained that the next narc could be given at xx time and wrote the time on the whiteboard.

    ANd I brought the narc when it was available.

    I also think you did well by offering prune juice as a compromise.

    i think I also would have tried to nicely explain that unless 2-3 days have passed without a regular BM, a laxative isn't needed.
    Last edit by vintagemother on Oct 5, '16
  10. by   kimmyanne02
    vintagemother,

    I agree that psych nursing is very team oriented. You become protective of each other, and that is something I absolutely love about being a psych nurse. We all watch out for one another to keep the team safe. I'm not sure any other nursing specialty has that same bond among coworkers like psych nursing. I think that's what makes it all worthwhile.
  11. by   CareerStudent10
    I am currently in nursing school and working full-time as a mental health tech in a 6 unit stand alone psychiatric hospital. I currently work on our high acuity men's unit. I have worked at this hospital for about 2.5 years now and I began working on our child and adolescent unit. I have to say that the majority staff in the hospital I trust my life with. In terms of working in psych as a new nurse, I have seen that it is important to set boundaries with patients, staff and with yourself. It is important for us in a therapeutic environment to understand our own limits. It sounds as though you handled this situation well by reaching a compromise. It is also important to be aware of the dynamics of the milieu. I seen many times where one or two patients can change the environment and move the focus from treatment to chaos. I have also learned that many of my patients have been in the mental health system for years. These patient are fully aware of what to say and do to obtain what they want. I constantly remind myself that if it were not for those of us who are able to come to work every day and take care of these patients they may not have any other options. Every day is a new day and an opportunity to make a difference. Keep up the good work!
  12. by   EKUGRAD
    The Curse of The Borderline: When they say something to get you riled up, it contains some element of truth; i.e. "You really look good in pink, for a girl your size".
  13. by   Night
    I've discovered, after a LOT of practice and screw ups, that your tone and facial expression are key in managing manipulative patients in psych. I've had people bad mouth me and be snide as well. I've had some success with saying, very calmly, 'You know, that's kind of rude." It's also perfectly acceptable to let the patient know that you will be happy to talk to them when they calm down, then walk away. Learn to cuss in your head while keeping your face pleasantly neutral lol.
  14. by   Meriwhen
    Quote from Night
    I've discovered, after a LOT of practice and screw ups, that your tone and facial expression are key in managing manipulative patients in psych. I've had people bad mouth me and be snide as well. I've had some success with saying, very calmly, 'You know, that's kind of rude." It's also perfectly acceptable to let the patient know that you will be happy to talk to them when they calm down, then walk away. Learn to cuss in your head while keeping your face pleasantly neutral lol.
    I like to kill mine with kindness. Kindness with firm boundaries though.

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