After 23 years of nursing, very few things drain my energy like a manipulative patient. This has been a constant regardless of the position or setting I was working. I expect to be hoodwinked when caring for someone with a substance use, personality or eating disorder. But, in reality, a patient with any diagnosis can hustle their healthcare team.
Manipulation Defined
I recently read an article, written by Dr. Jeffrey E. Keller, who works where some of the most skilled patient manipulators live- jails and prisons. Dr. Keller defined manipulation as:
Quote
"In the medical encounter, it's what happens after a patient wants something he shouldn't have-- like a narcotic, a special diet, gabapentin, an MRI, a double mattress-- and won't take "no" for an answer. Manipulation comes into play when the patient attempts to engineer a "yes" out of your "no".
Recognition Leads to Preparedness
The best way to keep your sanity when dealing with a manipulative person is to recognize common tactics they may throw your way. In his article, Dr. Keller describes 9 types of manipulative patients and their behaviors.
Exaggeration
This tactic is used when someone tries to make their circumstances special when compared to other patients. The patient will attempt to make their need or want worthy of your "special consideration".
"I have never experienced pain this bad"
"I can't go on hurting like this"
"It's so much worse now than it was last night"
Belittling
Manipulative patients will often attempt to make your contribution or job role seem unimportant or undervalued.
"Nurse X knew exactly what to do to help me sleep"
"The nursing care at Hospital X was so much better!”
"The day-shift nurse would have called the doctor by now"
Belittling is usually paired with splitting.
Splitting
This is when you're compared to another nurse who would (or did) give the patient what they wanted. It may be the nurse in another facility or on a different shift.
"The other nurse pulled strings so I could move to a larger room"
"I never had to wait longer than 2 minutes for Nurse X to respond to my calls".
Threatening
Threatening behavior from patients can come in several different forms. Patients may communicate threats of physical violence either verbally or nonverbally.
Verbal: "I will come right off this bed and at you if I do not get something for pain.”
Non-verbal: Patient may clench fists, tense muscles or narrow eyes.
A patient may also make threats in the form of complaints.
"If you don't give me what I want, I will go all the way to the hospital administrator.”
"I have a lawyer and you will be hearing from her!”
Fawning
Sometimes patients use exaggerated flattery (fawning) as a way to manipulate you into getting what they want. We do not always know when we are being manipulated because fawning can be very subtle.
"I am so glad you are here tonight! I sleep so good when you are my nurse and I brag about you to everyone.”
Fawning can also take on a flirty or sexual innuendo.
"You look so fit. You must work out every day.”
"I love your cologne. What is that scent?”
Filibustering
Filibustering is especially exhausting because the patient is so relentless in their demands, you finally just give in.
"I am going to continue to push this call light until I get what I want!”
"I will come back to your office every day until I get a prescription for gabapentin.”
The Straw-Man Victim
A manipulator sometimes accuses the nurse of acting against a protected class instead of their clinical assessment or findings.
Champions
A champion is someone that pleads the patient's case from the outside and is usually a family member. I recently cared for a patient who demanded a doctor look at his rash in the middle of the night. Even though the rash was barely visible and not causing discomfort, the patient's granddaughter called the front desk also demanding that a doctor visit the patient within the next hour.
Champions can be challenging since they often combine manipulative techniques, such as splitting, exaggeration and intense filibustering.
Self-harm
There are patients who deliberately harm themselves to force you to do something they want. Examples would include:
A patient who deliberately falls
A diabetic who intentionally causes severe hypo or hyperglycemia
A patient who refuses venipuncture for lab work necessary for care
Stay One Step Ahead
It takes training, practice and experience to successfully deal with patient manipulation. If you are a new nurse, ask for help before you become overwhelmed by tactics your patients may use to get what they want. You can practice staying "one step ahead" by recognizing the different types of manipulation and having your response ready.
What types of manipulative behavior have you encountered recently?
