Nursing Care of Difficult Patients

Nurses must develop skills to deal with these types of patients. A health care professional need to examine their own emotional status and patience prior to delivering care to those labeled as difficult patients.

Morrison et al (2000) states "many nurses report feeling inadequately prepared to care for patients with extremely complex medical, psychological, and social needs."

"Nursing students may not have the psychological or life skills necessary for working in this kind of environment". (Morrison) There are many books and continuing education programs to learn these important skills.

The patient's "need for control can exhibit itself in a variety of ways. A common way is through the use of anger, aggression, and violence". (Haas, Leiser, et al, 2006). Sometimes, psychological components to these behaviors warrant evaluation by a mental health professional.

According to Haas, "a considerable number of patients who are labeled difficult...exhibit criteria for a diagnosis of personality disorder. These patients may be excessively dependent, demanding, manipulative, or stubborn, or they may self destructively refuse treatment."

A nursing home patient constantly summoned nurses for use of the bedpan. Each shift nurse labeled her as demanding and too dependent. They moved her call light out of reach and closed her room door, refusing to answer her calls and screams for assistance.

It was later discovered she suffered from a urinary tract infection with the primary symptom of urinary frequency. After completion of a course of antibiotics, the patient's symptoms resolved but, although not as frequent, she continued to request a nurse to assure she would receive an adequate response.

There was even an incident of a patient actually calling 911 from his hospital room due to the lack of response to his call light. Unfortunately, nurses labeled him a difficult patient because his needs required too much of their time.

It speaks negatively of the care provided at the facility when a 911 operator phones the nursing station to request assistance for the patient. Although stressed to their limits, it is inexcusable for nurses to ignore a patient requiring assistance.

Nurses must be very careful labeling a patient difficult, especially during shift report. Many nurses have a preconceived impression of the patient prior to even entering their room. The problem could have been related to other issues on the previous shift or in response to a particular nurse.

Silverman (2003) cited Dr. Michael Lubin as stating, "Just because they're difficult patients doesn't mean they don't have real concerns. You must never lose your temper".

Nurses should not insist patients follow their routine or set time of care but rather negotiate care at the beginning of their shift. If possible, it is beneficial to do this on the initial contact. The patient may be less tempted to call the nurse before the negotiated time and will understand emergencies may cause delays.

It is helpful to ask for advice from other nurses who have had success dealing with the difficult patient.

Haas states, "Negotiation is best if it occurs as soon as possible following admission to the hospital, before the violence starts. Unfortunately, once the anger and aggression start, most staff reacts and get into a power struggle".

Sometimes, regardless of how astutely a nurse provides care, the patient may be difficult anyway. It may be necessary to change assignments with another nurse if the patient remains discontented.

In one case, a hospital patient asked the nurse to clean him after a bowel movement when it was obvious he could do it himself. He announced that while he was in the hospital, it was the nurse's duty.

When she insisted he wipe himself, he jumped out of bed, limped down the hallway, took a shower and threatened to leave against medical advice.

The nurse notified the supervisor who changed her assignment. This satisfied the patient who needed some control over his care, in addition to being manipulative.

Patients may become angry when they do not feel care is equally provided or their care is rushed and without empathy.

A nurse who spends a few minutes to listen to their patient's concerns may allay anger and their feeling ignored.

Patients are not concerned with how many other patients assigned to the nurse. If the assignment is too demanding, the nurse should delegate asking their colleagues for assistance.

In an incident on a surgical ward, a nurse became angry with a patient who continued to complain of pain due to an inadequate dose of analgesic.

This nurse loudly proclaimed having seven other patients he had not seen because of the requirements of this "difficult" patient. Nurses on each shift treated the patient as being difficult and ignored his screams for help.

Instead of obtaining an order for a stronger analgesic, the nurse attempted to sedate him "until the doctor make rounds in the morning." This is personal as this happened to be my fiancé and I consequently notified the doctor.

After an emergency CAT scan, the doctor discovered a herniated and strangulated "dead" bowel requiring immediate surgery. He would have died before that morning.

In her article, Silverman lists the 10 commandments for dealing with difficult patients:

Do the right thing. Lubin states "you can be sued whether you do the right thing or not." Always attempt to approach problems with compassion and empathy.

Make sure the patient possess decision-making capacity.

Never discharge the patient without the best possible treatment. A physician should never abandon the patient; this is also true for nurses.

Document, document, document

Never lose your temper even with colleagues and other staff members.

Do not feel obligated to put yourself in danger of physical assault. Foul-mouthed patients can be very insistent ones. Take a course in dealing with disturbed patients.

Never be distressed by insistent patients.

Explore the possibility of depression in patients with "a lot of new non-descript complaints".

You still have the obligation to care for these difficult patients.

"Do not act as if ego or well-being is adversely affected by the patient's non-adherence to treatment." Most times their behavior is not a personal vendetta.

Every nurse will experience caring for difficult patients in their career. A patient may exhibit behaviors such as anger, aggression and other personality disorders possibly requiring consulting a mental health professional.

Negotiating care with the patient may allay many of these behaviors. It is important not to allow egos and power struggles to interfere with care of difficult patients, a legitimate concern may be overlooked.

Education in dealing with these types of patients will allow nurses to begin their shifts without a preconceived impression of the patient.

References:

Haas,L., Leiser, J. et al. 11/16/2006. American Family Physicians. Management of the difficult patient. www.aafp.org

Morrison, E., Ramsey, A.,& Snyder, B. February 2000. Managing the care of complex, difficult patients in the medical surgical setting. http://findarticles.com

Silverman, J. (May 15, 2003). 10 Commandments for dealing with difficult patients--There's always the supply closet. http://www.findarticles.com