DEALING WITH DIFFICULT PATIENTS

1. DEALING WITH DIFFICULT PATIENTS Presented by Lanette Anderson, MSN, JD, RN

2. Objectives • How to Detect the First Signs of a Patient Who May Be Difficult • Getting to the Root of the Problem: Ways to Identify Different Types of Disagreements • Keys to Dealing with Difficult Patients: What you Can & Cannot Do • Proactive Approaches to Help Solve Issues Quickly & Properly • The Importance of Communicating Concerns to Other Staff • The Importance of Appropriate Documentation

3. Introduction • Nursing is typically seen as one of the most trusted professions in national consumer polls • Part of that trust comes from our image as calm and kind health care providers who will address the needs of patients in a timely manner • The reality doesn’t always match the image of nursing • The practice of nursing can include stressful working conditions and situations in which calm is difficult to maintain.

4. DETECTING THE FIRST SIGNS THAT A PATIENT MAY BE DIFFICULT It may not always be easy! • Patients may not be obviously upset, frustrated, manipulative, etc. • We may need to look for non-verbal clues to determine how they really feel

5. IDENTIFICATION OF DIFFICULT PATIENTS • Unfortunately some patients may be labeled in this manner inappropriately • There are many reasons for patients to exhibit various behaviors • Emotional disorders including depression • Physical discomfort • Side effects of medications • Fear • Severity of situation • Others

6. IDENTIFICATION OF DIFFICULT PATIENTS • The patient constantly complains about symptoms (sometimes numerous) although there isn’t any actual clinical evidence to support the complaints • The patient may return frequently for care of these and other symptoms, demand referrals to other health care providers • Unusual use of clinical services such as seeking narcotic medications from a variety of providers

7. OTHER LABELS FOR THESE PATIENTS • “Demanding” • “Whiny” • “Bossy” • “Entitled” • “Manipulative” • “Seductive” • “Unclean” • “Too fat/thin”

8. WHAT DO WE REALLY MEAN? • These patients require additional attention • Their care is more complex • They may take up more of our time • They may present us with ethical dilemmas • They may cause us to be fearful or uncomfortable • We must remember that being difficult can be an important clinical sign!

9. THE PATIENT’S ROLE • The patient is also a team member • Many facilities provide patients with a copy of a notice of patient responsibilities and rules • The patient must provide accurate information about medications, current and prior health problems, symptoms, allergies, etc. • The patient must actively participate in decisions if possible

10. IDENTIFYING DIFFERENT TYPES OF DISAGREEMENTS • Is there a personality clash? • Is there a difference of opinion? • Is there a cultural issue that has not been addressed appropriately? • Is there a problem with the language and/or non-verbal communication between the nurse and patient? • Is the issue really with the nurse and not the patient? • Is the care that the patient is receiving actually sub-standard?

11. WHAT YOU CAN DO • Gather information • Read the chart for clues • Don’t just hear what the patient says, LISTEN • Encourage the patient to listen to you • Be nice • Set the tone of the conversation • Watch your non-verbal cues • Objectively discuss their behavior

12. WHAT YOU CAN DO • Be honest • Use terminology that is appropriate for the patient’s health literacy level • Protect your safety and the safety of others

13. SAFETY ISSUES • Violence against health care providers has escalated in recent years • Nationally crimes against nurses and other health care workers are as common as assaults against police and correctional officers • Many incidents are not reported • Administrative personnel at some facilities are reluctant to make incidents public

14. SAFETY ISSUES • Nurses in the ER are at the most risk of violence from patients and those who accompany them • The Emergency Nurses Association is engaged in a study to examine workplace violence in that area • The Bureau of Labor Statistics has reported that 46% of all violent acts in the workplace that resulted in missed days of work were against RNs

15. SAFETY ISSUES • Facilities should have policies in place to address the appropriate response to these incidents • Adequate security should be available to protect staff, visitors, other patients, etc. from violence • The physical environment should be assessed to determine whether conditions exist which could increase the risk of violent acts by patients against staff

16. WHAT YOU CANNOT DO • Lose your temper • Raise your voice • Label a patient as “difficult” in shift report or other discussions with co-workers • Ignore the problem and hope it will go away • Provide a level of care that is not equivalent to that of any other patient • Engage in unethical conduct

17. WHAT YOU CANNOT DO • Use social media to vent • Cases of misuse of social media sites by health care providers including nurses have been increasing • Boards of Nursing and employers have disciplined staff for discussing patient information/violating HIPPA

18. PROACTIVE APPROACHES • Accept your own limitations • Keep your promises • Be truthful • Anticipate the patient’s needs • Keep the patient informed • Seek help when necessary • Respect the patient without respecting his/her behavior • Additional education for students and nurses

19. PROACTIVE APPROACHES • If a patient threatens to sue you, the facility, etc. notify your nurse manager and the risk management department • Resolve any issues as quickly as possible once they become known • Use humor appropriately

20. COMMUNICATING CONCERNS TO OTHER STAFF • Must be done in an objective manner • Maintain confidentiality • Protect safety of other patients and staff • Remember that you are not expected to resolve everything alone • Protects your interests as well as that of the patient • Another staff person may be better able to manage the situation

21. THE IMPORTANCE OF APPROPRIATE DOCUMENTATION • Important from a risk management perspective • If an incident occurs document objective information on an incident report or other appropriate form • May be needed in the event of litigation against the nurse, facility, physician, etc. • Can provide for better continuity of care

22. SUMMARY • We can learn something from each patient and each experience • We must remember the situation that the patient is in • It typically isn’t his/her choice to be a patient, but it is our choice to be a nurse/other health care provider • We just CAN’T please them all!

23. Questions and Answers

24. References • Anderson, L. (2011). Professional nursing: Dealing with difficult patients. Retrieved from http://nursetogether.com. • Mulvihill, C. (1996). Dealing with the difficult patient. Retrieved from http://www.pitt.edu. • Quan, K. (2011). Dealing with difficult patients and family members. Retrieved from http://www.netplaces.com/health-care-careers. • Roberts, L. & Dyer, A. (2003). Caring for “difficult” patients. Retrieved from http://focus.psychiatryonline.org. • Wood, D. (2011). Violence against nurses: How can hospitals lower the risk? Retrieved from http://www.nursezone.com.

25. SPEAKER INFO • Lanette L. Anderson, MSN, JD, RN • Executive Director, WV LPN Board • Lanette.L.Anderson@wv.gov • 101 Dee Drive, Suite 100 • Charleston, WV 25311 • 304-558-3572