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Difficult Patients: Why They're That Way and How to Handle Them

They complain, criticize, shout, swear and may even try to hit you. Difficult patients are an unfortunate fact of life in healthcare. But knowing how to identify, understand and respond to them can make your work life safer and less stressful.

Identify Difficult Patients

It’s sometimes possible to predict which patients will likely become difficult, abusive or violent. Alzheimer’s patients, for example, tend to be moody, irrational and easily agitated. Those with cancer, end-stage renal disease (ESRD), a history of violent behavior or some psychiatric disorders are also prone to disruptive or violent behavior.

Watch for certain emotions, advises Christine Simms, RN, MSN, a psychotherapist in private practice. Isolation and fear can lead to anger, which can escalate into violence.

“Look for isolated patients who are cut off from their families and communities,” says Simms, a clinical specialist in adult and family mental health nursing. She has taught hospital employees and individuals how to spot potential trouble as well as how to manage conflicts if they happen.

Many patients also feel let down by their failing bodies, their illness or by being hospitalized, institutionalized or placed in a nursing home. Some experience spiritual betrayal, asking why God let this happen to them. “Cancer patients often feel betrayed, particularly if they are also feeling isolated and stressed by switching from competent caregiver to losing control over their life, spouse and children when illness strikes,” Simms says.

Understand Why They’re Difficult

For patients with dementia, mental confusion is at the root of many problem behaviors. “Because people with dementia misperceive their environment and the intentions of their caregiver, they often react in negative ways,” says Dan Kuhn, MSW, director of education for Mather LifeWays Institute on Aging. The more cognitively impaired people become, the less able they are to express or defend themselves.

Many ESRD patients are testy, often for good reason. “They are sick and may be depressed because of their illness,” says Dr. Godfrey C. Burns, nephrology section chief at Saint Vincent Catholic Medical Centers. “Many are frightened, have poor coping skills and have a personality that is hard to get along with.” ESRD patients also aren’t often prepared to go from a normal life to an indefinite regimen of thrice-weekly, four-hour-long dialysis treatments. As chairman of the End Stage Renal Disease Network of New York’s grievance committee, Burns helped reduce the number of complaints about disruptive patients over the last 10 years by instituting a formal approach to treatment and educating staff.

Response Strategies

Once you understand what makes some patients so difficult, it can be easier to follow the experts’ suggested dos and don’ts.

Make sure you:

Observe: Notice a patient’s words, voice or attitude to pick up on rising anger levels. Overly compliant behavior is also a warning sign that a patient has lost his identity and sense of competence, which can lead to vulnerability, fear, anger and violence. “Worries and loss of control often are triggers of aggression,” says Simms, who urges nurses to trigger a sense of capability in patients, not one of vulnerability.

• Connect: Uncover and directly address a patient’s underlying feelings with comments such as, “You sound worried. What can we do to help?” Establishing a personal connection can go a long way toward gaining cooperation, Kuhn says.

• Show Respect: Make eye contact, and try to approach patients at eye level. Always address patients as Mr. or Mrs., and speak in a friendly manner.

• Slow Down: Rushing can be counterproductive, especially when caring for those with dementia.

• Recruit Help: Enlist relatives to help break the isolation, create solutions and provide support.

• Be Informed: Know your employer’s patient bill of rights, as well as its policies and procedures for dealing with difficult patients.

Avoid:

• Bullying: Don’t use your caregiver status to threaten patients.

• Making Assumptions: Most patients are not intentionally abusive or disruptive. They often are responding to an irritation, vulnerability, cognitive impairment, inability to express themselves or loss of identity.

• Putting Up Walls: Distance just fuels patients’ anger.

• Tolerating Disruptive Behavior: Clearly explain what is unacceptable to avoid problems later.

• Taking It Personally: “You can’t expect that everyone at work will act pleasantly,” Godfrey says. “Interpersonal mishaps or confrontations are guaranteed when you work with the public.”

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