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
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.
When a patient is described as having “coded,” this generally refers to cardiac arrest. In such a case, urgent life-saving measures are indicated. This can happen within and outside of medical facilities. The benefit of the occurrence in a professional health care setting is that policies and guidelines are in place to address this life-threatening crisis. What follows is the perspective of responding to a code from an ER nurse.
Just as every patient is different, so is every code. The causes and outcomes of every code have to do with the characteristics of the patient in question: the history of present illness and, of course, their comorbidities. Timothy Wrede, RN, is a long-time emergency and critical care nurse in the suburbs of New York City, as well as a former EMT who has seen his fair share of codes. According to Wrede, nothing matters during a code so much as the team that responds to it. “It is imperative to ensure that a good team of doctors, nurses, and ancillary staff are working together efficiently in order to achieve resuscitation of spontaneous circulation (ROSC),” says Wrede.
According to Wrede, a veteran of level-I trauma care, when
it comes to staffing a code, less is more. Studies suggest
that thirteen is the maximum number of personnel participating in an effective
code. Included in this number are professionals that go beyond those
immediately at the bedside, such as pharmacy, lab, and spiritual services.
“There’s nothing worse than 25 people crammed into a patient room trying
to coordinate resuscitation,” according to Wrede. For him, the minimum is
five ‘in the box’, or in direct proximity to the patient, as well as one team
member ‘outside of the box’. “One doctor, three nurses, and two aides
are more than sufficient to obtain or sustain an airway while maintaining a
clear line of vision of the patient, the patient’s monitor, and other team
members,” he says. This consists of one nurse on either side of the
patient responsible for gaining peripheral IV access, administering IV
medication, and obtaining blood samples for lab work. The code
recorder, usually an RN, documents everything that occurs, including every
medication given, timing, team actions, compressions, defibrillation, and
Wrede’s description of the ideal code team is very similar
to the American Heart Association’s recommendation for high-quality CPR
teams. It includes a “triangle” of providers doing chest
compressions, defibrillating, breathing for the patient, and providing
medications, in addition to a code recorder and a physician outside of the
triangle. The physician acts as a team leader by making high-quality
treatment decisions, providing feedback, and overseeing team actions.
For Wrede, the most important times for a code are before and after it. Having a competent team with pre-assigned roles, as well as the opportunity to review and debrief afterward to improve the process continuously, and allow for best patient outcomes. Many hospitals address this by establishing a code team that arrives every time a code is called, with well-established roles, and protocols. Wrede’s experiences describe codes in the ED, although codes are generally run the same regardless of where they take place. The biggest difference is the patient context.
One can easily surmise that Nurse Ratched was not drinking kale smoothies, jogging daily, and taking long, hot baths. The facets of compassionate nursing care that Ratched famously lacked, such as kindness and generosity, seldom come from a nurse experiencing a sense of deficit within themselves. A lackluster approach to one’s work is generally the prerequisite for what is now a bonafide medical diagnosis: burnout.
The old adage goes something like this: you can’t give what you don’t have. This is no less true for nurses than for anyone else. The work of an effective nurse requires the maintenance of a certain level of physical fitness, sound sleep practices, sensible nutrition, and the fortification of a positive and resilient attitude. This is because the nursing model demands not just the carrying out of physical tasks, but a wholehearted relationship with the patient as a human, rather than a set of symptoms. Nurses can best enter into this dynamic with their own health and well-being needs already met.
More than Full-Time
Although many nurses work a full-time 40-hour workweek,
additional overtime and
per diem work is common. Because nursing skills are in high demand, it is
easy for a nurse to take on more than a full-time workload. In addition, many
nurses continue their schooling after being licensed as registered nurses, to
advance their career as either nurse practitioners, in leadership roles, or as
nurse educators. With these demands, in addition to personal and familial
responsibilities, one can see why some nurses let their own health lose
A Picture of the Healthy Nurse
A well-rounded routine of well-being includes the obvious undertakings of healthy eating, regular exercise, and adequate sleep, in addition to the oft-forgotten needs of fun, leisure, social support, and hobbies. Many studies show the importance of these seemingly superfluous features of one’s lifestyle as incredibly important to health and well-being. A rich lifestyle filled with healthy activities and robust relationships may be more valuable than the income overtime generates for many nurses, and for their patients.
Self-care for Caregivers
For the nurse who scoffs at the idea of self-care, consider this — self-care is not an alternative to patient care, but an essential feature of it. Nurses who score higher on happiness index scores are more motivated in their work and demonstrate the enhanced quality of their nursing practice. Furthermore, a well-rested nurse is a more patient nurse, and a fit nurse is a more energetic, capable nurse. Lifestyle balance that allows for creativity, friendship, recreation, and sound physical health help nurses cope with the gravity and sometimes tragedy encountered in their work.
Each nurse is free to determine for themselves what work/life balance, fulfillment, and well-being mean to them. For some, financial responsibilities may necessitate extra work; however, there is no nursing job worth sacrificing one’s health for.
Nursing leadership is an essential feature of any successful health care administration. For many in the profession, the terms nursing administration and administration are used interchangeably because any nurse leadership role includes administrative–or managerial– and executive responsibilities.
The chief nursing officer (CNO) of any health care organization is considered the acme position of nursing leadership; however, there are as many nursing administrative roles as there are nurses to fill them. Every position is unique to the organization that creates it and the nurse that takes it on. The typical trajectory of a nurse leader goes in the order as follows:
- Bedside nurse
- Charge nurse
- Nurse manager
- Department director
- Nursing leadership, executive roles, and beyond
The Value of Nurses in Health Care Administration
As evidenced by the above, those who advance in nursing
leadership gradually move further away from direct bedside care. Regardless, at
every level of administration, having experience with direct patient care as a
nurse is essential for constructive oversight. As such, rarely do nurses
advance into administration without a foundation at the bedside,
and for good reason.
Charge nurses and nurse managers directly supervise nursing
within specific departments, such as the intensive care unit, or operating
room. Some of them even take on patient assignments of their own, whether to
fill gaps in staffing or as a fundamental part of their role. Nursing
department directors act as a liaison between their unit and the larger
organization or community, representing and speaking on behalf of their
This might lead to them implementing evidence-based practice
or quality initiatives based on executive feedback and financial implications.
Nursing leaders, executives, and administrators direct and organize
systems-wide schema to better nursing and patient care, qualitatively, fiscally,
It seems the goal of nursing leadership and administration is a popular one for young nurses today. There are even resources for nursing students to establish themselves as nurse leaders while in nursing school, both through skill development and networking. For nurses who have the competence and resiliency to be nursing leaders, it is an opportunity to affect positively the quality of care patients receive, beyond the bedside.
Evidence-based practice is essentially a self-explanatory phenomenon. It’s the translation of the most current research insight into action. One commonly repeated definition of evidence-based practice is “conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” Evidence-based practice in nursing is not a matter of simply going from the lab to graphed data to the patient. As with any nursing principle, compassionate, individualized care is as important as the statistics that drive it. Thus, nurses who utilize evidence-based practice give the patient the dignity and respect to participate in their own care, guided by the expertise and resources of the nurse.
Nurses do not have the luxury of relying on what they learned in school throughout their career. As in any field driven by science and technology today, the onus is on the practitioner to stay current. In nursing and medicine, however, the patient’s well-being is at stake, rendering their obligation to stay current an urgent one. Whether it’s catering care to the needs of different patient populations or having the courage to ask questions that don’t yet have answers, the prudent nurse relies continuously on evidence-based practice as a guiding principle of his or her work.
From the Bedside to the Ballot
Although most nursing guidelines and institutional policies today are created based on current best practice research, many nurses are taking it upon themselves to up the ante and create nurse-driven initiatives. They are uniting in the spirit of staying current on best evidence for quality patient care in their respective specialties.
Beyond its relevance in caring for individual patients, evidence-based practice in nursing has made its way to the ballot. Today, health care legislation relies on evidence-based practice to enact laws that affect all members of the healthcare team, from the multidisciplinary team to the patient. One hot topic in nursing legislation today is nursing ratios and how they affect patient outcomes. Nurses are fighting throughout the United States to educate lawmakers and laypersons alike about the importance of quantity in healthcare quality, and with research to back them up, they are being heard.