Tips From the Field

Teach staff how to deal with difficult patients

Be assertive and stop their negative thoughts

Any patient can become difficult or unmanageable at times. Perhaps a patient, suffer ing from dementia or mental illness, will clench his fists and tell an aide or nurse they were sent to spy on him. Or a patient may become excited and shout when she speaks with a nurse. Whatever the problem, home care nurses can benefit from an inservice on coping with patients who become noncompliant, unpleasant, negative, or violent.

Home care agencies sometimes have patients who are so difficult that nurses don’t know what to do with them, says Carolyn Scott, RN, MS, national coordinator of the behavioral health program for Staff Builders Home Health Care in Chicago. "Nurses may not know how to respond to crying or anxiety or to the unfair anger directed at them," she says.

Staff Builders includes a comprehensive teaching module for nurses on handling difficult patients. Scott was one of the creators of this tool, which is part of the company’s Restore program. Verna Benner Carson, RN, PhD, CSP, national director of behavioral health for Staff Builders Home Health and Hospice in Fallston, MD, was the lead researcher and author of Restore. The program also teaches staff how to be more assertive, communicate more clearly, and help patients eliminate self-defeating thought patterns. Here are its key points:

1. Follow guidelines for handling difficult patients. "This area has to be fleshed out in terms of what kinds of patients we’re talking about," Scott explains. "Are we talking about dementia patients who are beating up on caregivers because they’re so frightened of getting a shower?" Or is the patient psychotic, experiencing hallucinations that tell him to kill the next person who walks through the door?

Nurses will need some training to understand how to deal with the various types of patients, because actions will be quite different depending on why patients are behaving irrationally. For example, the nurse might teach caregivers how to approach dementia patients in a way that does not alarm them. Caregivers might use a calm, gentle tone when preparing patients for a shower, for instance. Or they may help patients take baths instead, she says.

If it appears psychotic patients are not responding well to current medication or have stopped taking their medication, the nurse might call the psychiatrist to discuss making a change. Another strategy is to recognize the most important characteristic of potentially violent patients: a history of violent behavior. This may include threats, assaults, arrests, or a criminal record.

Violent patients also might have characteristics such as drug abuse, mental retardation, schizo phrenia, paranoia, borderline or antisocial personality disorders, and cerebral lesions. Psychological tendencies could include fear, an inability to tolerate stress, poor insight, tendency to blame others, childhood abuse, poor educational and social background, and a lack of social support systems.

Clinicians often observe violent patients exhibiting behaviors such as fist clenching; violent gestures; intense facial expressions of anger, hostility, and fear; refusal or sabotaging of medical procedures; generally being uncooperative; over-controlling behaviors; dependency; and helplessness. Nurses can defuse violent situations by doing the following:

• Take all threats seriously.

• Use good listening skills.

• Never try to deceive or disarm violent patients.

• Verbally acknowledge the patients’ emotional state to provide insight into how their behavior is perceived by others.

• Allow patients to vent anger in a nondestructive manner.

• Provide a quiet environment.

• Have a family member present during home visits, if appropriate.

• Avoid intense eye contact.

• Stay aware of patients’ personal space to avoid making them feel threatened.

• Avoid escalating their violent behavior.

• Use direct statements to set limits, such as "Jane, when you lower your voice, I will continue our conversation."

• Determine if patients are using street drugs.

• Recommend low doses of a sedative for elderly patients or those with medical problems.

• Use assertive behaviors, but adapt them from situation to situation.

• Trust your instincts. Don’t become involved in potentially dangerous situations, especially if a patient appears volatile. "If you’re going to be clearly threatened, remove yourself from the home," Scott advises.

• Be prepared for any emergency situation. Carrying a cellular phone is recommended.

2. Use thought-stopping techniques. These techniques are a type of cognitive therapy, Scott says. "It’s kind of an interesting process that psychiatric nurses use with patients who are very negative in their thinking and ruminating about dire consequences." A very simple technique is to take a rubberband and put it around the patient’s wrist," she says. "Every time the patient thinks a negative thought, they should pull the rubber band back so it gives them a little whack."

The same technique could work by suggesting patients imagine a stop sign every time they have a negative thought. As patients become more aware, those concerns might begin to subside. "This works well with patients who don’t do well on medication. It gives them hope they might get some relief from their fears," she says.

Once patients become aware of their negative thoughts, nurses can discuss how those thoughts can be altered into positive ones. The idea is that a nurse or other clinician could help a patient take a negative thought or a depressed mood and, through talk therapy, turn these into more realistic thinking and a more positive mood. (For more details, see Patient Classroom, p. 11.)

3. Offer examples of assertive behavior. Nurses and other home care staff who deal with difficult patients must learn assertiveness skills because clear, effective, and firm communication is key with such patients. Staff Builders’ Restore program defines assertive behavior as setting goals, acting on them in a clear and consistent manner, and taking responsibility for the consequences of those actions. Assertive people are able to stand up for the rights of others as well as for their own rights. Nurses should use assertive behavior when patients become difficult, which includes taking measures to ensure their own safety, Scott says.

Education managers can show staff how to develop assertive skills by focusing on the following points:

• Demonstrate respect. Assertive statements do not violate the rights of others or cause them to lose face. These types of statements are made with a relaxed, attentive posture and appropriate eye contact, and they are spoken in a calm and friendly tone. For example, assertive people will not hide in global statements, such as "You always do this and mess things up." Instead, they might say, "I worry whenever you do this."

• Use "I" statements. When a statement begins with "I," it suggests the speaker accepts full personal responsibility for his or her own feelings and role in the conflict. "You" statements, on the other hand, sound accusatory. "We" statements may be made when the speaker wants to explore an issue together with the listener. Examples of "I" statements include empathetic ones, such as "I understand that . . . ." or "I hear you saying . . . ." Other types describe the speaker’s feelings or thoughts about a situation: "I feel that . . . ." or "This situation seems to me to be . . . ."

• Make clear statements. Avoid questions, especially those beginning with "why," because they put the listener on the defensive. "How" questions are OK because they ask for neutral, fact-based information. Clear statements might include those that state expectations, such as "I want . . . ." and "What is required by the situation is . . . ." Clear statements also might list consequences such as "If you do this, then [state positive outcome] will happen" or "If you don’t do this, then [state negative outcome] will happen."

• Be firm. Use a firm, moderate presentation because it is often as effective as what you’re saying in conveying a message. On the other hand, a soft, hesitant, passive presentation can undermine the assertive message, and a hostile, harsh, and aggressive tone can increase the conflict.

• Acknowledge your personal feelings. It’s OK to agree to disagree.

• Focus on the present: People can learn from the past, but no one can change it, and because the future is never completely predictable, you should focus on the present. The present is the only reality people have much decision making power as to choosing how to act.