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Nurses are resilient in difficult situations such as grave illness, calamity, and chaos. However, many nurses can have difficult situations that can seem more frequent—which is the management of the difficult patient. The loss of control causes certain people to behave differently as a patient than they otherwise would. Difficult patients range from mildly uncooperative to downright belligerent.  

The reasons for their attitudes vary, from mental health issues, organic sequelae of the disease process for which they seek treatment, to simply mistrust—sometimes justified mistrust—of health care professionals. It is important for the nurse to know how to work with, and “win over” the difficult patient for their own sanity and practice, and especially for the patient’s well-being.

1. Take the Time to Listen

Many patients don’t trust nurses, doctors, and other health care professionals. They may have had a bad experience or perhaps they are understandably frightened in giving the responsibility of their well-being to another. The first step in fostering trust is understanding, which begins with listening.  

Even if the nurse can’t give a patient exactly what they want or change their treatment protocol, listening bridges the gap between the patient and the health care team. This engenders a cooperative spirit, where the patient feels empowered and more like a participant in their own care. 

Although it’s important to help the patient understand the intricacies of their medical treatment, it is often more effective to just hear them out. This may not be easy for the acute care nurse who has five sick patients and a head full of tasks to complete, but even one or two minutes of meaningful, uninterrupted time with a patient can make a world of difference. 

2. Be Culturally Aware

Cultural competence is a buzzword now in health care. Patient populations are incredibly diverse, particularly in urban institutions. This has become a notable challenge in the provision of care. For example, a foreign patient who is too proud to admit the significance of a language barrier doesn’t open themselves up to a health care team that is too obtuse to notice their lack of understanding. Many cultural traditions and practices have ranging effects on patient treatments, whether it’s a matter of etiquette, dietary restrictions, or the propriety of certain life-saving treatments.  

No nurse is expected to be an expert on every culture, but it is their responsibility to be objective and professional. Even if a patient’s cultural beliefs go against the nurse’s beliefs, it is the professional’s duty to bridge that gap. Bringing objectivity, professionalism, kindness, compassion, and willingness to work with each patient’s cultural needs is essential to establishing a cooperative rapport with that patient.

3. Consider Their Emotional and Spiritual Needs

Many patients’ experience of illness is worsened by unmet emotional and spiritual needs. This could be acute distress related to the disease itself, or an exacerbated state of a preexisting psychological condition. This cannot be ignored, even if the patient’s disease or injury being treated is seemingly unrelated to their mental health. It is important to utilize available resources when a patient’s condition suggests that they may need assistance outside of their primary health team. This includes counseling services, social work, and institutional chaplains.

4. Recognize the Importance of Recreation

For some patients, laughter truly is the best medicine. Diversion may seem an unlikely intervention for the difficult patient, but it is frequently an effective one. Establishing a rapport with a patient that includes lightness and humor may generate a sense of ease for them. Naturally, every nurse that employs humor must do so with prudence.  

This is not a matter of the nurse entertaining the patient, so much as recognizing recreation as an integral part of every human’s well-being. Just because a patient is ill doesn’t mean they can’t enjoy a fun movie, their favorite music, a game, or camaraderie. The nurse may find themselves with a much easier patient when they’ve given them a little bit of diversion and fun.

5. Bump It Up

In no scenario is a nurse to tolerate abuse or inappropriate behavior from a patient. Every health care facility has policies in place to protect nurses from this kind of treatment. Nurses should know these policies and how and when to employ them.  

Often the process begins with notifying the charge nurse about an inappropriate patient from which they will use their discretion and authority to handle the situation. It may be a matter of consulting psychiatry or pain management to adjust the patient’s medication. The nurse may need to call security if the patient is hostile or violent and danger is imminent. No matter the circumstance, communication is key. No nurse has to do it alone.

For every difficult patient, one important task of the nurse is to document thoroughly. No matter the cause of the patient’s behavior, the paper trail that leads to its resolution is a critical element of the patient’s well-being and the team taking care of them.

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Nancy Swezey, BSN, RN, CNOR

Nancy Swezey received her BSN from Columbia University. She now practices in New York City in the operating room where she has worked as a staff nurse, and currently as a care coordinator specializing in head and neck surgery. Nancy is also pursuing her advanced practice degree at CUNY Hunter where she assists the faculty as a research assistant, focusing on nurse education and module development.

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