Are you heading into your 4th semester preceptorship, or perhaps you’re a new grad getting ready to start out on your own. By now you’ve seen a glimpse of some of the types of difficult patients/families that the RNs have had to deal with. Sometimes the challenge is subtle and easily handled…like the patient with 10 family members who all call for separate updates (that one’s easy…designate ONE spokespserson), or it could be more overt with hostile, aggressive behavior that makes you question the continuity of your own personal safety.
With that said, being a nurse will test every single one of your people skills…after all, you are dealing with people and usually not during the best of times. For us, dealing with illness and life/death situations is commonplace. But, for our patients and families, they are dealing with something they’ve likely never experienced before and are under immense amounts of emotional and physical stress. Keep that in mind, and it can help you approach even the most difficult situations with more compassion and less frustration.
Here’s a quick little snapshot of the most common types of difficult patients & families and how to deal with them.
The manipulator: One of the most common types of difficult patients you’ll encounter is the manipulator. These patients will pit nurses against one another, lie and do whatever they can to get their way. You may hear things like, “Oh, that nurse yesterday was just awful. I’m so glad I have you today instead.” Guess what? They’re going to say the same thing about YOU to the next nurse…it’s a way for them to try to get you on their side so you’ll feel indebted to do things for them. Usually they want things like ice chips when they’re NPO, or extra pain medicine when they don’t really need it.
There was a patient on my unit recently who was on a strict fluid restriction…once he’d had his 1200mls per day, that was it. Well, of course, he would drink all his water at once (despite being told he should space it out over the course of the day), then ask anyone who came into the room to get him water. If the nurse hadn’t communicated his fluid restriction to the rest of the staff, he could have easily talked some unsuspecting nurse or nurse’s aid into bringing him more water than he was allowed to have. After he realized we were on to him, he started getting up to the sink (somehow staying connected to the monitors) and fill his pitcher himself. We finally had to call someone from maintenance and have them come disconnect the plumbing in his room.
Speaking of fluid restriction (which everyone universally hates, by the way), an easy way to manage this is to start the day by bringing in exactly the number of cups that will meet your patient’s fluid limit. For example, if their restriction is 1200 mls, you’d bring in 5 cups. Once a cup is finished, toss it out. When they’re out of cups, they’re out of fluid. Period.
Speaking of manipulators in general, setting clear boundaries and expectations is key. Communicating these boundaries and expectations doesn’t stop with the patient…you have to get the other nurses on the care team on board as well. If the nurse on NOCs lets him have ice chips and you don’t…you’ve been set up for failure big time.
The helpless patient: Some patients are just so helpless, you wonder how they manage to take care of their own affairs at home. My favorites are the grown men who suddenly aren’t able to clean themselves after using the bedside commode. Ummm…no. If someone is genuinely ill, gravely weak or injured, then of course we’ll help clean them up. But a walkie-talkie patient who suddenly decides he can’t take care of his own cleaning needs after using the toilet makes me suspicious that he’s got some kind of sicko nurse fantasy going on. With patients like this (or any patient who is much too helpless for their situation) I always start by asking, “How do you take care of these things at home?”
The next thing to do is determine what barriers are keeping them from managing on their own at this time…is it the IV line that’s in the way? Can you saline-lock them for a moment? Often it’s the pulse-ox probe…can you take it off for a bit? If they’re just straight-up being too helpless (or I suspect they’re a bit twisted) I will sometimes follow up with, “We need to get you more independent, otherwise we’ll have to talk with the case manager about a skilled nursing facility until you’re strong enough to take care of your own basic needs.” The thought of going to a SNF usually clears up any ambiguity about what they can and can’t do. Yes, I admit…it’s a bit underhanded but it does get the point across if you have to actually go that far. Typically, asking patients how they manage at home or how they PLAN to manage at home is enough to get them to realize they’re not completely helpless and CAN actually do something. And in the case of the perverts, it lets them know you’re onto their game.
The annoyed patient: Some patients are just so darned ANNOYED by all the nursing/medical interventions that you wonder why they came to the hospital in the first place. This is why I always explain things at the beginning of the shift (or whenever I receive a new admit) and let them know about the frequency of interventions…especially if it’s in the middle of the night. I might say, “Because you had a stroke, I’ll need to wake you every hour to monitor your neurological status. I’ll try to let you sleep in between as much as I can, but the first few hours of an ICU stay can be very busy with all the tests and medications.” If it’s someone in DKA, I let them know they’re getting a fingerstick every hour. I never ever give anyone in ICU the perception that they’re going to get hours of uninterrupted sleep. In fact, I even give them a heads-up…”It can be difficult for patients to sleep here…there are a lot of alarms and monitors beeping off and on. Plus, it’s called INTENSIVE care for a reason… the frequency of assessments and interventions can get intense. I’ll try to cluster things together as much as I can, but I just want you to be aware of what to expect.”
If you’re working on the floor, you can let the patient know right off the bat that you’ll be in three times a shift to take vital signs (yes, even in the middle of the night), and that you or one of the nurses aids will be doing safety rounds regularly…along with any other interventions, meds and whatnot. When they realize these assessments/interventions are for their own benefit, they typically fuss a lot less.
Which brings us to…
The refusing patient: One step up from the annoyed patient is the patient who refuses things. “No, I don’t want my vitals taken now…no, I don’t want to be repositioned…no, I don’t want you to check my blood sugar.” With patients like this, sometimes it helps to approach them with requests so they feel a sense of control. For example, “I know you’re having pain Mr. Johnson. You’re due for some Norco now if you’d like, but I’ll need to check your blood pressure first to make sure it’s safe.” So the patient has a choice…no blood pressure check or no pain meds. Usually it’s a pretty easy decision. If you have a patient who flat-out refuses, then just be sure you document it clearly. You might write something like, “Pt refused to be repositioned. Pt educated on necessity of frequent repositioning to avoid skin breakdown. Pt AAO x 4, acknowledges understanding, continues refusal.” Then go on about your merry way. If the patient is refusing things that are more vital…certain assessments or medications, then you definitely need to let the MD know. If they’re not going to let us treat them, they need to go.
The aggressive patient: Patients are aggressive for different reasons…encephalopathy, alcohol withdrawal, dementia, brain injury, hypoxia, fear, anxiety…or simply just because they’re being jerks. I took care of a patient recently who was going through alcohol withdrawal (which is THE WORST, by the way). He was paranoid, mean, threatening and had tried to punch and kick the NOC shift nurse at least twice. My philosophy with aggressive patients is personal safety first. Always. At one point he was swinging the call light around like a mace…do you think I checked his blood sugar? Nope. But I did chart every encounter in excruciating detail…quoted his words (“I’m going to kill you” was said more than once) and at the end of the note simply wrote “blood sugar not checked due to concerns for personal safety.” And, of course, let the MD know. Also, let your charge nurse know, too. Sounds like this guy needs a sitter…or a security guard standing by.
With some aggressive patients, you can use the buddy system…one nurse distracts him while you do whatever you need to do. This usually only works if the patient is confused and easily distracted…other times you’re both at risk for getting a kick to the face. Use your judgment and never put yourself in harms way.
The watchers: You know that creepy, exposed feeling when six pairs of eyes are on you, watching your every move? If not? Don’t worry…you soon will! Some families are “watchers” and it is unnerving to say the least. They don’t talk to you, they don’t talk to each other…all conversation ceases when you walk in the room and they lock their laser beam eyes on you and watch. Sometimes I honestly think it’s not intentional…after hours of sitting at the bedside with a sick family member, you’re simply the most interesting thing in the room. But others do it out of a suspiciousness that is hard to assuage. And if they’re also the type who take notes on every thing you do? You’re in for a while other level of scrutiny…and it can be stressful.
When I have a group of watchers (or note-takers), I find that if I explain absolutely every little thing that I am doing, their anxiety decreases, they stop the staring and everyone is generally more relaxed. These are the type of people who want to know EVERY medication you’re giving, every assessment you’re doing, why every intervention is necessary. It makes for a LOT of talking throughout your shift, but when it pays off, it’s worth it. When they can see that some of what you are doing is benign (and not because they’re loved one is getting sicker) they sometimes relax a little bit, such as “This is a flush of normal saline to keep the PICC line working smoothly” or “I’m cleaning around the catheter to help prevent a UTI” or “The doctor changed her IV fluids based on her blood sugar improving, so I’m switching that out now.” Seriously…if you don’t explain even the simple little things, their anxiety remains high and you’ll feel like you’re walking into a fishbowl every single time you enter the room.
The demanding family: The important thing to understand about the demanding family is usually that they are trying to exercise SOME kind of control when faced with a situation in which they feel completely helpless. This is the family that will come out to the nurse’s station to tell you there’s a speck of sputum on dear mom’s pillowcase…or to tell you that the monitor alarms are pinging. If they show up mid-shift, you’ll notice you get a LOT busier as soon as they arrive. A common thread amongst these types of families is that they will fixate on the non-essentials because that’s all they understand. While you’re running around trying to hang levophed, get a central line placed and pump in fluids, they’re telling you that “mom looks uncomfortable, she never lays on her side like that” or “her lips look dry” or “can we get a new gown?” or my favorite, “when are you going to feed her?” and my other favorite, “could I get a cup of ice water?”
Yes, believe it or not, while you are running around busting your hump to provide awesome nursing care for their loved one, many families will ask you to do things for THEM…fetch them ice water, make them coffee, bring them blankets and toothbrushes, troubleshoot their phones so they can get on the hospital wi-fi, find the football game on the TV, etc.. And while I do like to make family members happy, I will not do it at the expense of their loved ones care. Typically in cases like this I’ll make it clear that the RNs are not their personal wait staff by saying something like, “Our volunteer comes in at 4:00 and he’d be happy to help you with that,” or “Let me see if I can get one of our volunteers to come assist you while I manage your mom’s blood pressure.” They usually get the idea (not always, but usually!).
If they are simply fixating on the wrong things because it helps them feel in control (for example, asking when we’re going to start feeding a freshly-intubated patient who is on three pressors) I will briefly explain that once mom is stabilized and through this acute problem we’re having RIGHT NOW, we can address things like nutrition, home med reconciliation, gown/linen changes and the like. And then stick to your word. Without their trust, you are sunk.
As for the family that goes into panic mode with every beep of the alarm or IV pump…a brief review of the alarms and monitors in the room goes a long way toward getting them to relax. People will panic when the IVF goes to TKO mode…”IS MOM DYING???” No…she’s just running low on lactated ringers…I’ll be right back. Even the SCDs pump alarming will send some families over the edge. Though it’s nice of a family member to let you know of an alarm you can’t hear from outside the room (like the IV or the SCDs), instruct them how to use the call light and let them know it’s not Threat Level Midnight whenever something in the room beeps.
If they’re in the ICU, a brief overview of the monitor and its many alarms is often helpful as 90% of those alarms are completely benign, transient or due to a poor reading. I always tell the patient/family that ALL of the nurses on the unit keep an eye on the monitor alarms, that the alarms are usually nothing to get concerned about and that as long as I’m not getting excited, they don’t need to get excited. I usually tell them, “If there were a serious issue, you’d see 4 or 5 of us in here in a hurry….so please don’t let the constant pinging and beeping worry you. Worrying about the alarms is my job, your job is to be here of your loved one.” Usually this works.
The slovenly family: When my hospital built a brand-spanking new building and we moved our ICU over to the new facility, we instituted a few brand-spanking new rules as well…mainly no family members allowed to sleep in the room overnight and no eating in the room (unless you’re the patient, of course). Why did we have to make these fancy, shiny new rules? Because unfortunately, many family members pushed the limits a bit too far. I am not kidding when I say there would be people CAMPED OUT on the floor, in the recliners, bringing in all manner of junk to eat, leaving their mess everywhere. It was gross. So gross. I am thinking of one family in particular. Their family member was sick…very sick…and they were doing The Vigil. Seemingly, not out of any grand concern as they rarely interacted with the patient or inquired about her status…I suspect they just didn’t have anything else to do and coming to the hospital was SOMETHING TO DO. They brought in their fast food and treated the whole endeavor like a family reunion. But it gets worse…so much worse. One of the family members was rather lazy…would plop herself down in the recliner chair and just STAY there…and eat. That’s all she did…sit, talk and eat. After a full day of this, we had to ask the family to leave the room for a procedure and guess what, folks? She had peed herself in the chair. Rather than get up and go to the bathroom, she’d just gone in the chair. WHO DOES THAT???!?!?!?!?!?
When family members insist on bringing in all manner of things and it starts to encroach upon the room, I set boundaries. I’ll tell them we need to keep the bedside table clear for nursing/medical supplies and they can have some other area for their things. Of course, if the patient is alert and oriented, the bedside table belongs to them so they can eat and have access to their belongings. But more often than not, in the ICU the patients are too sick to care about their table and we need the space for tube feed irrigation trays, dressing supplies and whatnot. The point is, don’t let the family’s “stuff” impede upon your ability to provide safe and efficient nursing care. When they realize you need to be able to get to the spare trach tube or hemostats in an instant, they’ll understand your need to keep things tidy and organized.
The questioning family: Along the same lines as the “watchers” are the families who question everything. “What is that?” “Why are you doing that?” “What medication is that?” “Did you know he’s on 25mg metoprolol at home, why are you giving him 50mg?” “When is the doctor coming by?” “When was her last BM?” and again with the “When are you going to feed her?”
While we definitely want families to be involved, the constant interruptions can be incredibly distracting. Dealing with the questioning family is pretty much identical to dealing with the watchers…just proactively explain everything and eventually the questions will slow down as they learn to trust you, the doctors and the routine of the hospital. This is one of those times you REALLY want to understand all your meds before you walk in the room….I guarantee you this will be the time someone will ask, “Why is he getting that?” and if it’s a drug you’ve never heard of before OR that has multiple uses, you want to be sure you know the rationale. Sometimes looking through the doctor’s note will clue you in if the pharmacology reference doesn’t. OF COURSE, you should never give a med you don’t understand, but sometimes the indication for it can be a little uncertain…for example, some patients take Lexapro for depression while others take it for chronic pain…a quick read through the notes will let you know why your patient is getting it.
Now, after all that, you’re probably thinking, “WHY AM I DOING THIS? DO I REALLY WANT TO BE A NURSE?” Don’t worry…most patients and families are wonderful to work with and they will reaffirm your decision to become a nurse over and over and over again. But when you get a “challenging” assignment, knowing how to handle it can go a long way toward turning things around and keeping your focus right where it belongs…on the patient.
Looking for more strategies for dealing with difficult patients and families? Kati at FreshRN has a great series covering this very topic…check it out here! Her proactive approach works beautifully for all types of situations and I wholeheartedly agree with every word of it…definitely worth a read!