Working With “Difficult” Patients

This question may be addressed in school, however, I wanted to ask since practice is so much different than textbook theory. Have you ever had to deal with difficult patients? Examples would be non-compliance or worse. I read another nurse’s post including examples of things like biting, scratching, and spitting. I understand the potential is there but how common is that really? And how do you handle this?

– A question submitted from an anonymous person from Tumblr

I’ve been pushed, screamed at, cursed at, and some old lady tried to body-bump me across the room (with a chest tube – ha!).  It’s just part of the job, and something I used to dread but now I don’t care.  There are different tactics for different kinds of difficult too.

Let me clarify the word “difficult” – many patients are confused due to their disease process.  They don’t know what they’re doing, most of the time.  It’s important to give people the benefit of the doubt, but have some clear boundaries for behavior with realistic expectations.

Know which battles to fight.  For example, if my super irritated detoxing patient is flipping out about all his meds.. I’m not going to spend 20 minutes convincing him to take a Colace.  It’s not happening and I don’t care at all about that Colace now.  I’m going to crush those blood pressure pills and Ativan and throw it in some applesauce and try to get him to take that one bite for me.  And if I think it’s going to be a problem or am concerned for my safety, I’ll call my buds in security to stand right next to me to make sure he takes them.

It’ll be a power struggle, again, just know which battles to fight.  Don’t get into a power struggle for the benefit of your ego.  Nurses that get the most bent out of shape by these patients usually have quite a bit of an ego/control thing and flip out when the patient doesn’t do as they’re told.  Getting mad about this is worthless; it’ll just stress you out more and make it more difficult to care for them and your other patients.

Here are some different approaches:

Grouchy/grumpy/mad about doing anything:  Befriend them, joke with them, figure out something they like and bring it up over and over again.  Be on their side.  And then when you need them to do something, present the task as a favor.

Belligerent/combative:  Restraints, security, and Haldol are your best friend.  When they curse at you, “you will not speak to me like that” is a good thing to constantly say.  Minimal options; “this is what’s going to happen..” and tell them how things are going to go.  I love my security guards with these patients!

Demeaning:  I spend as little time at the bedside as possible and explain things in a matter-of-fact way.  I’m here to help, not get verbally abused, so my touchy-feely nursey side goes away for these patients.  And make sure I am in there when the doctor rounds.  A lot of times we’re “just nurses” to these patients, so I make sure to go in with the doctor so they know I mean business.  Again, “you will not speak to me like that” is another go-to phrase of mine.  And usually, when you say that (and if they just needed someone to be assertive back), they’ll feel like a jerk for acting like that and be super nice for the next 4 hours.

Way too talkative/avoiding doing things:  Talk, but know when to stop them and say “let’s get down to business” (to defeat… the Huns!)   And then you can start singing Mulan to them.  I always blame the doctors with these patients and say something like: “the doctor insists you get out of bed three times today, no excuses.  Let’s get the first one out of the way now.”  Again, minimal options and redirect the conversation to the task at hand.

As far as safety is concerned, I’ve never felt unsafe.  Security gets to my unit quickly, I can tie a restraint faster than I can wipe a butt, and can draw Haldol up even faster.

Does anyone have any more tips related to dealing with difficult patients? Do you have another kind of difficult patient and a specific way of handling them?

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