SAUSALITO, CA (ASRN.ORG) --As nurses, we are in the business of caring and healing.  We pride ourselves on our ability to see the needs of others and help.  But, let's face it; there are some patients that you will find it hard to have empathy for.  We need to maintain a non-judgmental, attentive manner for every patient, but when their behavior is intimidating, threatening, or time consuming that can be easier said than done.  Frustration, uncertainty, anger, feeling manipulated or controlled by a patient makes them difficult to connect with.

These difficulties can come from the patient's side or the nurse's side.  Realistically, the nurse's emotions define the patient as a problem.  For instance, how much more difficult is it to give care to someone who holds vastly different values and feelings about healthcare practices?  It shouldn't be harder, but sometimes it really is.  Then there is the patient who has boundary issues, or drug abuse issues, or anger issues, or hygiene issues, or you name it.  On any given day, on any given shift, a patient can become "difficult" for you to deal with.  Still, you must find a way around the problems to provide the best care you can.  How does a nurse deal with the difficult patient?

Compassionate and effective care requires objectivity.  The first step is often to separate the emotions from the experience and restructure it into something that can be addressed rather than something that is only felt.  Ask yourself questions and assess the situation without getting caught up in anger or other ineffective emotions  Remember that the patient's actions or behaviors are difficult, not the patient themselves.  Try looking at the situation from their perspective.  Try to reform your own perceptions of the situation as "challenging" rather than "difficult".  The emotions from both you and the patient, or even another nurse, can make the situation more taxing.  Learn not take their behaviors personally.

Consider transference and counter-transference factors.  Are the feelings that the patient is projecting toward you based on previous bad experiences with healthcare professional?  Likewise, are you assigning perceptions about the patient based on your previous experiences with a similar patient?

Often, issues with difficult patients do have an emotional feeder.  This is especially true when dealing with the angry or hostile patient.  There is usually more to the problem than what can be readily seen.  Challenging behaviors may be associated with mental illness, substance abuse, disease process, life crises, poor coping or social skills, or any combination of patient specific factors.  The difficult patient is often trying to tell you that they are currently living a difficult life.  They may lack trust in healthcare as a whole, feel mistreated or ignored, have personality problems, social or financial problems.  It could also be something as basic as communication breakdown or misunderstood cultural differences.  The real parameters of the situation need to be identified early before the problem can escalate.

Try to maintain a reasonable and neutral tone to all care and interactions, but deal with disruptive behaviors immediately.  These patients need support and understanding with established limits and parameters.  Set up consistent rules, parameters and expectations, but allow the patient time to adjust and build trust.  In most cases, resorting to medication or other methods of restraint can be inappropriate and caustic rather than a solution.

Use verbal and nonverbal communication effectively.  Tame your emotions, and show an openness to resolve the conflict.  Avoid placing blame or making hasty judgments.  Acknowledge the patient's feelings, but also objectively communicate how their behavior affects your ability to care for them.  Make sure to use appropriate language that the patient can understand.  Listen attentively to the patient and address their concerns.  Even when it's hard, give complements and help the patient feel valued by you.

Finally, it's okay to acknowledge your limitations in providing care to certain patients.  Conversely, you may be better able to deal with certain types of behaviors better than a coworker.  Whenever possible these difficulties need to be taken into account in patient assignments.  Patient care is a collaborative effort that requires training, understanding, and cooperation on every level.  When difficult situations arise, staff and peer support can ease a lot of the stress associated with the challenge.  Remember to express appreciation for others who help you care for the patient, and support for their own patient care efforts.  It is also important to help maintain supportive communication with other nurses who help care for the patient.  Additional staff training to help find ways to interact with compassion and model appropriate behaviors for others can be requested.

References

Chou, C. Dealing with the "Difficult" Patient. Wisconsin Medical Journal. 103:6, 2004.

Bookhardt-Murray, L. J. Approach to the Patient with Difficult Behaviors. HIV Medical Alert: For Primary Health Care Providers and Health Professionals.  7:3, 2004.

Managing Difficult and Frustrating Patients.  Texas Medical Association.  December, 2005. 

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