How Do You Deal With “Difficult” Patients? 

Nurses deal with all kinds of patients, and some interactions are more challenging than others. Some patients get labeled as “difficult”. How we think about patients is important and can significantly impact the nurse-patient relationship and quality of care. Changing our habitual thinking can be good for the nurse, the patient, and the care that’s ultimately provided.

What Exactly is a “Good Patient”? 

Dr. Joan Naidorf is an emergency physician whose book, “Changing How We Think About Difficult Patients: A Guide for Physicians and Healthcare Professionals,” explains how we can improve our work experience by changing our attitudes toward our patients, especially the most challenging ones.

When asked what constitutes a “good patient,” Naidorf states, “When I talk to nurses about interactions with difficult patients and families, it’s useful to contrast those with the interactions that go well.”

She continues, “What characteristics are we looking for? We define ‘good’ as mature, rational thinkers who want to partner with the healthcare team to address their problems. We think good patients treat us respectfully, cooperate, and comply with our present plan. We want questions or disagreements to be presented courteously. We enjoy interacting with good patients and can experience great satisfaction.”

Where Does Our Negative Thinking About Patients Come From?

How do we form negative habits in our thinking about patients? Naidorf has an answer.

“Nurses, like all humans, have a strong negativity bias. In medical care, we don’t jump to the conclusion that that leg cramp is something minor — we’re concerned about a life-threatening deep vein thrombosis.

“Secondly,” Naidorf continues, “nurses pick up this negative talk during their training. In the classroom, high ideals and ethics are discussed: successful nurses are organized in their thinking and documentation; they’re determined to be empathetic and efficient.”

According to Naidorf, something happens to challenge those ideals. “In the real world, student nurses hear their mentors and colleagues speak in derogatory and mean-spirited terms. A sense of distrust and resentment can permeate the workplace as more cynical nurses harshly judge how patients dress, speak, or behave. It’s easy for inexperienced, impressionable people to think: ‘Well, this is just how it is — these must be the facts.’ But these aren’t facts — this is just a story everyone in the workplace believes.”

What are Common Thought Distortions About Patients?

Naidorf relates, “There are many unhelpful thought patterns. One common one is all-or-nothing thinking. We often think there’s only one way to get something done or think about a problem. This is a thought distortion because there aren’t just two solutions to a problem — there are dozens. Patients who challenge us can have a very different way of thinking and want to do things their way. A small shift from all-or-nothing thinking can help us find common ground with patients.”

“A second is the tendency to place ourselves in the victim role,” Naidorf states. “People with a victim mentality tend to complain a lot. They also tend to blame the doctors, the supervisor, the pharmacy, or the patient. ‘Why does this always happen to me? Why did they put him in my zone? Why do I have to do another septic workup?’ Assigning blame to others and playing the victim places you in a disempowered role. A victim has no power to act or find solutions. We aren’t victims, and we have the power to solve problems and find solutions.”

Thought distortions are important to recognize, and there’s one more Naidorf highlights.

“A third distortion is resisting reality, which comes up in many ways. We think to ourselves, ‘This person should’ve been wearing a helmet; that mom should’ve given the child something for fever; that guy should stop getting drunk.’ We can’t change the past, and wishing that things should be different only makes us suffer in the present.”

How Do We Change How We Think About Challenging Patients?

“Nurses can do much to change how they think about ‘difficult’ patients,” says Naidorf. “They can remember that many of their thoughts are just thoughts, sentences in the mind that can be changed. Becoming aware of thoughts is the first step to changing them. We can ask ourselves better questions.”

Naidorf has more advice. “When falling into all-or-nothing thoughts, ask: ‘Could I be wrong? Are there other approaches that could work equally well?’

“You can also ask, ‘What else is true here? Is that drunk man someone’s father? Does that mother love her child? Is coming to the ED the only way this family can access care?’ Small shifts in thinking can lead to more feelings of curiosity and empathy.”

Lastly, Naidorf wants nurses to truly focus on their thinking, which can lead to actual changes in behavior and practice.

“One thing you can do is define what the event or circumstance is in as factual a way as possible. No adverbs or adjectives should creep into those definitions. A person with some illness or injury comes to the medical office or urgent care center, and the nurse has a thought about that person. We can choose thoughts with more intention that serve us and them better.”

And when negative thoughts arise, Naidorf has a plan.

“Some negative thought will invariably pop up, but we can force ourselves to question if anything else is true. If we think the person should not have come in, we can counter that with, ‘We have all the right people, equipment, and medicines to help this person.’ With positive thoughts, nurses will take actions that further the mission of helping the patient and will get more satisfying results.”

But can we always be positive? Naidorf doesn’t expect perfection.

“Sometimes we want to be disappointed or sad about what happens at work, and it’s appropriate and helps us empathize with patients. We work in places where people experience tragedy, so it would be weird to pretend to be always happy,” she reassures us. “It’s ok to feel sadness, disappointment, and frustration — temporary emotions that pass through our bodies. Feeling all the emotions is one amazing part of being a human nurse.”

Own Your Humanity — and Patients’ Humanity, Too

As Dr. Naiforf points out, nurses are human beings, and humans have feelings and flaws. We’re also capable of great empathy and kindness. Our patients are also humans; their lives can be complicated and painful, and we often encounter them at their very worst on some of the most challenging days of their lives.

No matter how stressful our work may be, when we summon our humanity, we can be more curious, thoughtful, and capable of being present without projecting negativity where it doesn’t belong. And sometimes, we’ll fail and fail again. But every day gives us a chance to start anew.

If you can change your thoughts, you can also change your experience and your patients’ experience. And that is a worthy endeavor indeed.

The post How Do You Deal With “Difficult” Patients?  first appeared on Daily Nurse.