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Practice Comment

'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.

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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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