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'A methodical approach can help manage difficult patients'

We all encounter and dread “difficult” patients. Behaviour that is intimidating, abusive or time consuming can make us feel uncertain, manipulated, frustrated and angry.

We shouldn’t feel guilty about these feelings - nurses are not supposed to be judgemental but we are not robots, and some patients we simply don’t like. However, while we don’t have to like them, we do have an ethical and legal obligation to rise above our feelings and provide the best care we can - which is not easy in the face of continued provocation.

Irritation with challenging patients can be compounded by fear that they may complain. Complaints have increased by over 40% in the last decade and often lead to disciplinary action and even litigation. Whether nursing standards have fallen or not is a moot point, but people are certainly less reticent about speaking up.

Legally, we are stuck between a rock and a hard place. Any zero-tolerance policy regarding difficult patients eventually falls foul of our basic duty of care. We cannot simply walk away. And neither should we - while some people may just enjoy making life difficult for others, most challenging patients have varying and legitimate reasons for their behaviour - be they mental health or drug-related issues or simple fear, pain or communication problems.

We need a safe, stress-free solution to this grey area. In other areas where a resolution is not clear, such as intractable pain or chronic wounds, our response is not emotional but systematic and rational. Perhaps we should apply a similar reasoning here. It seems counterintuitive but fostering a more distanced attitude (at least on the surface) may be more effective.

A methodical approach that could serve both our patients and ourselves is found in the teachings of non-violent communication; if it could be distilled into one handy epithet it would be “make a conscious decision to not be offended”.

This suggests that allowing oneself to become offended at another’s response causes defensiveness and the erection of unhelpful barriers. It does not claim that patients won’t make you sad, hurt or angry, but points out that, by choosing to not become offended, you can separate the emotions from the experience and restructure it into something that can be addressed rather than only felt.

I’ve discovered that at worst it defuses confrontations and enables me to retain a sense of moral superiority (a kind of mildly satisfying failure). At best, it leads to a change in difficult patients: on seeing that their behaviour does not elicit drama and tension, they may give up or even develop respect for you.

Don’t take difficult behaviour personally, and accept that, while some situations cannot be resolved, they can be made more manageable. We can’t change patients but we can think of situations as “challenging” rather than “difficult”. As a result we may, in time, see difficult patients more as an ongoing challenge than an immediate affront.

Stephen Riddell is community staff nurse in Dumfries and Galloway

Readers' comments (124)

  • it's difficult not to take it personally when a patient or relative makes a false accusation about a member of staff, openly criticises a member of staff to other patients, calls you fat, ugly, stupid, simple, useless, plus of course the racist comments.

    i am not talking about patients that don't know what they are doing, these are people who are just plain nasty and in any other situation you would be advised to just walk away, it is very hurtful, very demoralising and can cause undue stress to staff. I have seen staff in tears over patients and relatives behaviour, this is not acceptable but no-one cares.

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  • Above comment- I can totally relate to you and I think the majority of healthcare workers can now. I think society in general these days are sometimes unappreciative of things, very seldom do i have a patient say "Thanks for that, I appreciate it" and when i do it's lovely :)!
    However, on the other hand, it is very difficult to manage patients and relatives which are mean to you and make the ward a horrible environment to be in. For example, I've been threatened by patients, had to call the police in because patients are dealing drugs in the ward or being very abusive towards the staff and sometimes this escalates the problem.

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  • I think we need to make a distinction between difficult patients and abusive ones. Staff do not have to tolerate abuse, i most certainly do not.

    I do agree with the article about choosing not to be offended by those who set out to be difficult, often they are seeking a reaction and by not giving them one we can signal to them that their ploy is not working.

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  • why should we have to play stupid mind-games with our patients and their visitors, isn't the job hard enough without having to put up with any more crap.

    if someone is deliberately being nasty just to get a reaction then walk away, don't get involved, let them play their silly games.

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  • Its quite hard not to be offended when one is called a "fat f***ing c**t" by a patient's relative.

    Similarly, it is also a tiny bit disturbing to be told that "I'll be waiting for you to leave work" or that your house will get burnt down if you do not comply with the patient's wishes.

    But, thankyou Stephen, for your article: I feel much better now (not).

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  • people can be extremely offensive and rude, racist, ageist, sizeist - we are told patients and visitors will be 'removed' if they bully staff - what a lot of rot, who has ever seen anyone removed from the ward?

    I like the old classic 'I pay your wages' - put another record on.

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  • Thank you Stephen, it's worth a try

    Though I too find it frustrating that there is no support for staff when they are abused. WHAT happened to the "Zero tolerance" campaign?

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  • staff do not have to tolerate abuse but they do, on a daily basis, from patients, relatives, colleagues, managers, the media, regulatory bodies.

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  • how do patients and their relatives manage 'difficult staff'?

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  • My father was a difficult patient and his behaviour was challenging. I was still afraid of him in my 40s. Even when he was dying. Some (younger male) nurses thought we were the ones at fault, because he was a nice old boy, but the older female nurses knew and understood. But they all looked after him, despite everything. He died a good death. I work in another part of the NHS but I wrote to the DNS to thank the staff on the ward. It wasn't til long afterwards we discovered he was autistic. We had no idea. Sorry for posting, I'm just a manager, but what with the nurse who committed suicide, I remembered all the nurses who'd been good to us and I don't want you all to think no one cares because they do. So on behalf of all the difficult people you look after, thank you.

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  • being 'difficult' is not the same as being rude, unpleasant, ungrateful, racist, ageist, sexist, loud and a show-off.

    some people feel the need to be in control which can come over as being 'difficult', they want things done their way, they don't take advice and often we wonder why they came into hospital because they don't want our help or advice.

    some people are used to being in control of their lives and find it difficult when they have no control over their illness.

    some people are just bossy and over-bearing and won't tolerate anyone telling them anything.

    some people are just horrible and ignorant and have zero people skills.

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  • michael stone

    Anonymous | 13-Dec-2012 11:27 am

    Very good question!

    Some staff and some NHS organisations can be hugely annoying, especially when they become rigidly fixed to some sort of absurd 'protocol-led behaviour'. It just leads to entrenched positions and escalation.

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  • michael stone

    Anonymous | 13-Dec-2012 7:51 pm

    A very instructive post - I think it was a good post, so I don't see why you need to apologise for posting it ?

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  • michael stone

    Anonymous | 13-Dec-2012 7:51 pm

    Further to my previous post, when I had very little time.

    The main point of interest, is:

    'It wasn't til long afterwards we discovered he was autistic. We had no idea.'

    So, his 'challenging' behaviour:

    'My father was a difficult patient and his behaviour was challenging.'

    was presumably related to the autism - or, it could have been related. But not knowing he was autistic, affects how other people 'see' his behaviour, and how much 'blame' is assigned.

    Personally, I have come to realise that I am not very 'empathic', so I'm probably 'close to , but not quite, Asperger's' - I gather that the difference between Asperger's and autism, is that autistics can't 'see' their own situation ? I have noticed that 'being not very empathic' sometimes gets me into trouble with 'touchy-feely' people.

    Off-topic, demented people are living (I think) in a world that looks different to them, than it does to us (even to me) - they often cannot make 'sense' of what is going on around them, and that must be truly terrifying for dementia patients !



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  • anon 11.27 - patients and visitors can speak to the senior nurse on duty, ask to speak to a site manager, speak to PALs, write to the hospital, write to the various patient support groups or the newspapers.

    Despite what the NHS Constitution claims, staff don't have any support when someone is rude to them, we just have to grin and bear it. We manage it ourselves by going off sick, going to see our GP/occy health for stress related illnesses and then inevitably either retire early or get the boot.

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  • how many reports does one hear of patients or their relatives not being listened to or taken as seriously as they should be? this can result in significant delays in access to diagnostic tests and / or the start of treatment which can can, in some cases, cause an exacerbation of their condition or leave them disabled with pain or dysfunction which in turn may affect their daily living activities, quality of life and livelihood or at worse be life threatening or fatal.

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  • not directly related but may be of interest

    http://www.medscape.com/viewarticle/775407
    How to Handle Disruptive Physician Behaviors
    An old and complex problem is coming under new scrutiny in an era of patient safety. Find out how to detonate the bomb.
    December 12, 2012

    http://www.medscape.com/viewarticle/775758
    Nurses Remain Nation's Most Trusted Professionals
    Jenni Laidman
    Dec 06, 2012

    http://www.medscape.com/viewarticle/774256
    Carefronting: An Innovative Approach to Managing Conflict
    Rose O. Sherman, EdD, RN, NEA-BC, FAAN
    Disclosures
    Am Nurs Today. 2012;7(10)

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  • I really do not envy staff their roles at times, no one should be subjected to verbal or physical abuse, although sadly I can think of one specific nurse who deserves everything he gets. I will never forgot or forgive his manner when my husband was admitted three years ago. Fortunately, ICU staff were quite simply amazing and I was in awe of their manner and skills.
    I specialize in the dementia care environment and have done quite a bit of work with Security Departments looking at how an improved setting can reduce aggression and violence by 60%. I appreciate that this isn't always the case, but I do believe that the environment can play a huge part in maintaining calm whether an elderly ward, acute setting or a waiting room. I have seen a patient physically attach a person sweeping the floor in an hospital waiting room - hours of waiting on hard grey chairs, looking at grey walls with no idea of how long they are likely to be and possibly in pain too. In some cases, ie kidney dialysis, patients go through this many times every week and have additional worries too about prognosis. I am not saying this is the answer to all problems, but if it can calm some patients and take the pressure of some nurses, surely it's worth considering?

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  • envionment does play a part in anxiety, we all know that - as does noise and lighting.

    i don't like being 'stared at' by relatives, I find it very peculiar and intimidating - I just ignore it now, smile and move on to the next job. it's pathetic when they stare at you, snigger, make childish comments and are just trying to start some silly argument, it's embarrassing. i also find it rather silly when you hear patients and relatives deliberately speaking loudly on their mobile phones, criticising the staff, the food, I guess they are just bored. One patient recently was shouting down the phone, demanding to be taken home from this awful place with the awful staff and there was no-one at the other end of the phone.

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  • michael stone

    Hmnn - 'perspective issues' are being highlighted in the recent comments - things look different according to 'where I you stand' and perception is also influenced by one's previous experiences, which are different for staff/patient/relative in many cases.

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