August 5, 2013 1 Comment
By Martha Tice, RN, MS, ACHPN, Clinical Nursing Editorial Director, Nurse.com
What prompts us to call patients or their families “difficult”? The list of reasons can be long. We label people by their medical diagnoses (i.e., COPD, ESRD, sickle cell) because we see them as demanding and unhappy regardless of anything we “do.” We judge them by their requests (“I need my pain med now!”) or failure to adhere to a prescribed plan of care (“He just needs to stick to his salt and water restrictions!”) without taking time in our busy day to understand the motivations behind their behaviors.
My nearly 40 years as a clinician focused on caring for the chronically ill. Even when I worked on a surgical floor, I was caring for people with end-stage disease undergoing solid organ transplant. Before joining Gannett Healthcare Group last year, my career included teaching self care to patients newly diagnosed with diabetes, working in both acute and outpatient dialysis, and 15 years in hospice home care. I started out in hospice as an on-call nurse, became an RN case manager, and finally transitioned into teaching/mentoring nurses new to hospice while continuing to provide consultation on pain and symptom management as a clinical nurse specialist. Needless to say, I have encountered many people in crisis who challenged this value instilled in me during my undergraduate education: Look past the behavior and honor the person by understanding I cannot judge his or her experience by my own. That’s a noble philosophy, right? Have I always succeeded in adhering to it? No way! But I began to get a real handle on it while working with end-stage renal disease patients, and the skills I honed there served me well when I began to work in hospice.
It isn’t realistic to think we can change the behavior of everyone who confronts us, particularly when they or their loved ones are ill or dying, but we can change the way we respond. In the vast majority of cases, the behavior has nothing to do with us as individuals. We elevate our importance when we react as though it does. So the first step in dealing with difficult patients and families is not to take their actions personally. That can be hard when they are blaming you for their anger or behavior. Our continuing education module CE344-60, Staying Cool Under Fire, can help you identify your communication style and provides tips for communicating with people who are angry or upset.
Here are some skills I have acquired that help me diffuse difficult situations:
Acknowledge the difficulty of the situation with statements that convey empathy such as, “I can’t imagine how difficult this must be for you. If you would like to talk about it, I am here to listen.” At the same time, don’t take responsibility for their problems. While I acknowledged with my dialysis patients that I could not begin to understand how difficult their dietary restrictions and treatment schedules were for them, I also conveyed to them that adhering to it was their decision to make and when they drank too much, ate too much salt or skipped a treatment, they had to deal with the consequences of those decisions. “Nurse, you made me cramp!” during treatments to remove excess fluid was no longer a point of conflict for us. We did discuss their goals for care and strategies to achieve them, which often included ways to adhere to their prescribed dialysis schedules, diets and medications.
Set boundaries if behavior becomes disrespectful or threatening. Convey that you want to be respectful, but yelling, hitting, or abusive language affects your ability to address their needs and concerns.
If necessary, remove yourself from the situation with the explanation that when they are able to speak more calmly you will return and address their concerns or needs.
Use concise language to get your messages across. Long explanations are difficult for people to synthesize when under stress. (You may need to set limits on the time you can spend discussing a topic when the same issue is revisited repeatedly.)
Also, recognize that you can be more effective if you let go of the need to help and fix everything. Rachel Naomi Remen, MD, author of “Kitchen Table Wisdom,” said helping and fixing drain our energy and compassion, while serving can be healing for both the patient and the caregiver. Working in home care quickly brings home the fact that the patient is in the driver seat. They may defer driving privileges to others, but these are still their journeys to travel. I can share my expertise and provide options, but it is up to the patients to decide what works for them. Coming to that place in my professional growth made it possible for me to serve patients in hospice care for over a decade despite facing some very angry people.
Practice these skills on people you love. After all, raising teenage children can present some of our greatest care giving and communication challenges!
A strategy I used when visiting homes of those stuck in angry or destructive behaviors was to take three slow breaths to calm my mind followed by reading these words from Dr. Remen before getting out of my car:
“Many times when we help we do not really serve. … Serving is also different from fixing. … Abraham Maslow, said, ‘If all you have is a hammer, everything looks like a nail.’ Seeing yourself as a fixer may cause you to see brokenness everywhere, to sit in judgment of life itself. When we fix others, we may not see their hidden wholeness or trust the integrity of the life in them. Fixers trust their own expertise. When we serve, we see the unborn wholeness in others; we collaborate with it and strengthen it. Others may then be able to see their wholeness for themselves for the first time.” ― Rachel Naomi Remen, MD
How do you deal with difficult patients? Let us know in the comments box.