Difficult patients can be defined as abusive, drug-seeking, delirious, demanding, angry, manipulative, or sexually explicit. They may frequently “fire” nurses or other healthcare team members. Sometimes, they will even refuse treatment or leave the hospital against medical advice. Whichever way, these patients can make or break you and your job satisfaction. But there are ways to cope!
In my seven-plus years of bedside experience as an ICU nurse, I was often purposely assigned these patients because I was skilled in caring for and dealing with difficult patients. Through the years, I have found that most problems with patients can be solved by validating and acknowledging their fears and emotions, as well as by employing empathy. The following article will examine some real-life tips to help care for this patient population, which might not be so difficult after all.
But First, Check Yourself
Is it the patient who is being difficult, or is it you? It might have even been the previous nurse who cared for the patient. More often than not, the previous nurse will tell me in a report that the patient was “on the call light all night,” “was seeking pain medications,” or “was trying to pull out their lines,” or any other story. While I will recognize her struggles, I try to formulate my own opinion of the patient. I also make every effort to set aside my own biases while reading the medical history of the patient and respect the previous nurse’s assessment.
It is also important to understand how difficult it is to care for others when you are chronically stressed at work or at home. Meaning, immediate stress relating to an overwhelming patient assignment, being short staffed, or picking up overtime might negatively influence your ability to cope. Additionally, any stress you have in your life outside the hospital will inevitably cross over to your work life. All of these factors could lead to burnout and, consequently, the depersonalization of your patient. Once you have reached this point, it is nearly impossible caring for any patient, let alone caring for and dealing with difficult patients. So, check yourself first.
The hospital is a scary place, and if you have ever been a patient, you might know how frustrating it truly is. I am a control freak by nature, like many other cohorts of healthcare professionals, but it is important to remember we as providers are stealing control from our patients. For example, we tell them what to do and what time they can do it. Often, their breakfast, lunch, and dinner are pre-determined if they get anything at all. If they hit the call light to use the bathroom, it might take us twenty minutes to get there and untangle their IV tubing and telemonitor wires. That’s before we can even help them to a bedside commode where they are forced to use the bathroom with minimal privacy.
As a provider, I try to give the patient as much control as possible. If the patient wants pain medicine, I write out a schedule of the times the patient can have pain meds, and I do my best to deliver them accordingly. I let them pick a time to do physical therapy, and I coordinate with the team. If the patient does not want to get up, I simply say that we can get up any time within the day and offer to let them choose. I let them pick the side they want to be turned to. As much as I can, I give them a choice. And if they still do not want to comply, I weigh the cost and benefits of the treatment. I do not get mad because, after all, the patient has the right to refuse care.
Give Patients Something to Do
In the ICU, some of our patients are locked inside one room for days on end. Imagine being in a single space, all day, every day. This tip relates more to the delirious or memory-impaired patients, and they can be some of the hardest treat. They pose a great difficulty because, many times, hospitals will not justify a sitter for the patient, and they do not qualify for security. This leaves restraints as your only option to prevent the patient from pulling out lines and tubes. Typically, restraining a patient makes the situation worse and is poor patient care.
Therefore, before I load my patients with mood-altering medications or restrain them, I make every effort to give them an activity, patient condition permitting. For a patient with dementia who cannot get out of bed, I wheel my computer to the bedside and chart while she or he folds washcloths or reads magazines. For my agitated patient who can walk with assistance, I gather the troops and do several laps around the unit. Finally, for the chronic patient who is delirious and has been in the ICU for far too long, I wheel her or him outside for some sunshine therapy. While I understand it takes time and resources to perform these tasks, you are bound to have a better day overall once they are completed.
Whatever you fake, your patients will know. During one of my most frustrating days as a bedside nurse, I was caring for two chronic patients. Both were in isolation, both considered difficult, and both had been in the ICU for months. My assignment was so busy that I was rushing in and out of each room, completing task after task. Robotically, I passed meds, did my safety checks, and skimmed my diagnostics. They were both agitated, pulling at lines, and continuously hitting the call light. I could not understand what they wanted because they both had tracheostomies and were unable to speak. Their delirium was altering my ability to do my job, and I just wanted to care for them. I reached my limit of tolerance when one of my patients hit the call light and started banging it on the bed. I stood at the door of the room and told her, very sternly and inappropriately, to stop. Then I stopped, shocked with my own behavior. I had let my stress get the best of me.
I quickly realized I needed ten minutes off the floor. I sat in the bathroom to breathe for those ten minutes, as many of us do, and collected myself. Reflecting upon the day to that point, I had anticipated the stress so much that I never took a moment to stop and listen to the patient or truly empathize.
I went back on the floor and sincerely apologized to both of them. I explained that I wanted them to both have a good day and asked how I could help. I believe both patients felt the empathy and appreciated the validation because, after that, my day completely turned around.
As a general rule, everyone, not just patients, wants to be heard. I am a talker and a big personality. But, when it comes to my patients, I make a heartfelt attempt to sit back and listen. Patients have yelled at me many times in my career, but I never yell back. I look at them in an acknowledging manner and let their fears diffuse through their words. Then, I apologize for the situation, even if it is not my fault, and I ask open-ended questions. I often find the patient is scared or has outside stressors that have not yet been verbalized, and she or he just needs to talk. I want the patient to trust me so that I can provide the best possible care, and listening is a key part of actively earning trust.
A Note About Violence
It is important to note that many patients are mentally impaired and can be dangerous no matter the tactics you employ. If you ever feel physically threatened by any patient, or the patient is violent in any way, security should be called immediately. No matter how busy your unit is, you should never care for the patient alone or enter the room alone. The patient should have 24-hour surveillance by security until the threat has been entirely resolved, which may mean security needs to stay with the patient for longer than they want to. If you feel uncomfortable in any way, speak up and do not let security leave.
Workplace violence is rampant in healthcare settings in comparison with other jobs. Twenty percent of nurses report being physically assaulted, and 50 percent report being verbally abused within a 12-month period. These are astounding numbers, so please speak up to protect yourself if warranted.
Dropping the Label of Dealing with Difficult Patients
After synthesizing all of this advice, my hope is that you will see that we aren’t dealing with difficult patients. Many patients who are labeled difficult are, in fact, not; they are just human. Their behavior is an outward reflection of what is happening internally, like it is for you and me. Being honest, open, communicating effectively, and knowing when to ask for help can solve many problems for you and for the patient.
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Danielle LeVeck, DNP, ACNPC-AG, CCNS, RN, CCRN is an ICU Nurse Practitioner, blogger, speaker, and social media influencer, who strives to empower and inspire nurses from all backgrounds, to partake in regular self-care and multidisciplinary teamwork, for the sake of providing optimal patient care. Follow her on Instagram and Facebook for her latest.