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Nursing Issues: How to Deal With Difficult Patients

Introduction

The various technological innovations have entirely changed the world. Moreover, these advancements have lead to rise in medical conditions. However, appropriate handling of these medical conditions; it is mandatory that the medical practitioners have appropriate information, and expertise to ease the amount of energy that they require in handling these conditions. Moreover, the measures that medical practitioners adopt must undergo some cost-benefit examination to ensure that there is no wastage of limited resources in using these measures. This helps to ensure that resources are conserved and used for other purposes. For effective provision of medical care, the values held by patients, the required clinical expertise and necessary evidence should be primal in arriving at a decision that will lead to maximum clinical results. Nevertheless, according to An et al., approximately, one of six patients faces difficulties during his/her visit to the hospital (Anne, Rabatin, Manwell et al, 2009).This research paper aims at identifying a specific medical condition, among the many medical conditions that exist today to form a practice issue (Rehman & Johnson, 2006). Through critical analysis of this medical condition and employing different methodologies for study, the research aims at devising different strategies that are employed to increase success in medical care, and how these strategies can be improved by identifying the gaps that exist.

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Overview of the Hospice Setting

Working as a nursing practitioner is a challenging occupation. It is difficult to leave this profession because of the patients that one handles. The patients attract a lot of empathy from the practitioner that encourages an individual to offer all their efforts to help in relieving the patient’s conditions (Rosenfield &Jones, 2004). I currently work as a nursing practitioner in a hospice setting. The uniqueness of our hospice setting separates it from other hospice settings. The patients are individuals who do not only suffer from terminal illnesses but also other diseases that are in the process of treatment. The setting consists of inpatient and outpatient facilities. The organization always has many patients who require admission. This is impossible because the setting does not have sufficient bed spaces to accommodate all the patients. However, other patients prefer outpatient services because they take the inpatient services to be threatening. This organization is a non-profit organization whose main objective is helping the ill live a positive life. I work in the inpatient unit that has a total of 36 beds for the patients. We are situated in Cape Coral Fla. This is a strategic location because, from the statistics, areas around this place have high cases of terminal illnesses that prompted the government to setup this facility.

Since the setup, practitioners in this setting have been experiencing many difficulties that interfere with the normal operation of the facility. These problems are blamed on patients who prove difficult to handle. The inpatient wing is full of terminally ill patients. These patients have physical, emotional, spiritual, and social problems that compound to cause different patterns of behavior (Klein, Najman &Kohrman, 1982). This is due to the notion that they are living their final days and are bound to die in a short span of time. Consequently, they display a lot of hostile behavior towards any party who interacts or associates with them.

The inpatient unit has never been left out of this antisocial behaviors common among terminally ill patients. The medical staff has reported many cases of combative behavior from patients who are admitted to our inpatient unit. Many of the staff sustained injuries from these forms of maltreatment. They report having been injured while attending to patients. This has made it hard to administer palliative medical care to such patients, which is a vital concern to the administration. Moreover, the staff has not been the only victims. These combative behaviors have been directed towards other parties who interact with these patients. Family members have a taste of this aggression and have trouble when they visit relatives admitted in this unit (Steinmertz & Tabenkin, 2001). This has slowed the process of spiritual care because family members play a crucial role in relieving the spiritual and emotional problems that ail these patients. Other patients who are admitted into the setting have also sustained injuries from these behaviors (Rehman &Johnson, 2006).

Practice Issue, Policy, and or Clinical/Administrative Issue to be addressed

These behaviors have generated concerns in many quarters. I have preferred to research on this clinical issue because of the potential threat it poses to the general wellbeing of the organization. Healthcare organizations have ethics that guide operations in such institutions. The hospice setting that handles patients of this delicate nature needs an effective system to supervise accomplishment of these codes of conduct. This is done irrespective of the individuals who participate in this wrongdoing. The combative behavior demonstrated by patients in this setting goes against these ethics. The failure to respond to this mistreatment by patients, is partly blamed on the organization, because it has failed to respond or adopt measures that can limit or end this animosity. This has prompted research to find the methods that the administration can adopt to solve this predicament (Kirmayer, Groleau &Looper, 2004).

The hospice setting receives many patients with different types of terminal illnesses. These illnesses are in different stages and advance at different rates. The terminal illnesses registered under the hospice setting include Acquired Immuno Deficiency Syndrome (AIDS), Dementia, cancer, delirium, Alzheimer’s disease and neurological conditions such as Parkinson disease.

However, combative behavior was evident in both inpatients and outpatients. This gave a wider understanding of combative behavior. A compromised was reached to include other behaviors such as verbal aggression, physiological responses, resistance to care by patients and catastrophic reactions that were characterized by mood swings. Patients who were handled under the inpatient wing demonstrated all these forms of behavior. Patients with different terminal illnesses demonstrated different forms of combative behavior (Klein, Najman &Kohrman, 1982).

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The research methodology employed the use of many sources to consolidate the relevant information necessary for completing this study. Many variables are used in the determination of the extent of combative behavior that an individual demonstrates. The research methodology used considered many variables to influence this extent of combative behavior. Age was a principal determinant of this level of combative behavior. High occurrence of combative behavior was evident in younger individuals who suffered from terminal illnesses. Physical aggression, which resulted to injury, was common among young patients. These patients experienced high level of frustration since their expectations of living a full life was short-lived by their illnesses. Older patients only expressed mild forms of antagonistic behavior such as verbal attack.

Research Methodology

For this study, I reviewed three different experiments. These experiments were carried out through the use of structured questionnaires that were handed to the doctors to fill. There are parts of the questionnaires that had multiple choice questions and other parts with open ended questions that required them to give brief descriptions. The answers were put in defined categories and the results presented in the form of percentages. The data collected was also presented in the form of pie charts and graphs to show the distinctions between the different categories. The findings were presented with accompanying write-ups to give proper descriptions of the findings.

Review of Experiments

In the first experiment, “the ‘difficult patient are as perceived by family physicians,” (Steinmertz & Tabenkin, 2001). The authors set out to find what experiences a family physician goes through when he encounters a patient he perceives as ‘difficult’. They arbitrarily chose 15 Board-certified family general practitioners, each with at least five or more years of experience as a notable list. The term difficult patient referred to individuals who demonstrated physical aggression and not those who were mentally challenged. (Steinmertz & Tabenkin, 2001). Another group of difficult patients is those with psychosomatic problems and the ones with many non-specific grievances.

The second experiment under review was by Faustino R. Perez-Lopez, who called it “Difficult (Heartsink) patients and clinical communication difficulties”. He gathered information from 101 physicians from 15 medical schools all corners of the United States. He found out that “approximately 15% of clinical consultations may be rated as ‘difficult’ by involved physicians (Perez-Lopez, 2011). From the experiment, he says that difficult patients can either have behavior problems or medical problems. Those with behavior problems can reveal stay-sick manners like disregarding problems, being non-compliant and abdicating responsibility. There are also those with demanding behavior who want to manipulate the physician and control their treatment schedule. Other forms of behavior that can make a patient difficult include whining, lack of focus, talking slowly and using abusive language. Patients who are difficult as a result of their medical problems will typically present with multiple complaints, chronic pain, average personality, bipolar disorder and substance abuse.

The third experiment under review was by Shakaib Rehman and Ralph H. Johnson, and it is called “Expanding our skills for dealing with difficult patient encounter”. The aim was to identify what constitutes a ‘difficult patient encounter’ and how to deal with it as a physician. The authors interviewed 40 medical practitioners in both public and private practice, in the State of South Carolina. From their findings, most doctors consider difficult patients to be those who are hostile or angry (49%) do not follow instructions (19%) and those who are too demanding or needy (19%). Other difficult patients are those who do not know how to explain their symptoms and those who ask too many questions (Rehman & Johnson, 2006).

Discussion

The medical meeting is supposed to result in mutual satisfaction for both patient and physician. However, there are times when physicians encounter difficult patients who end up making this encounter unpleasant, especially for the physician. Several studies have attempted to define and describe the difficult patient. These patients fall into four categories, namely the manipulator, the denier, the demander and the self-destroyer (Groves, 1978). Physicians find various social and medical conditions to be difficult. Some of the most common of these conditions include alcoholism and drug use, obesity, mental disease and, muscular skeletal diseases. Patients with these conditions are usually dirty and smelly, display anger, hostility and aggressive behavior. Dealing with angry patients is especially difficult for most physicians. In most cases, the patient expresses the anger in an open and obvious way, but there are few times when the anger may be expressed in more hidden ways like discordance between verbal and nonverbal communication. Most physicians evade addressing the irritation in their patients by disregarding it or changing the subject. They mainly do this to avoid eliciting more anger from the patient or wasting time on the issue (Rehman & Johnson, 2006). This is not helpful, and may lead to more anger from the patient, so the physician must learn ways of coping with such patients and other difficult patients in general. It should also be pointed out that the problem may not be with the patient only but also the physician. Many health practitioners are acknowledging that the problem is in the meeting between the two sides, and not the patient alone (Steinmetz & Tabenkin, 2001).

Author Title Year Question Design Sample Data Collection Findings Limitations Level of Evidence
Steinmetz D and Tabenkin H. The ‘difficult patient’ as perceived by family physicians. 2001 Who is the difficult patient? qualitative research Fifteen knowledgeable medical practitioners. They had experience more than five years Questionnaire with six open-ended questions The participants mentioned that the patients considered ‘difficult’ are not the ones experiencing some medical problems. They are people who behave rudely and want a secondary gain.
Patients with multiple non-specific complaints and those with psychosomatic problems are also difficult for the family physician
It was difficult to establish the exact causes of difficult behavior Lack of adequate databases to do thorough research
ttFaustino R Perez-Lopez Difficult (“heartsink”) patients and clinical
communication difficulties
2010 How do you deal with a difficult patient? Qualitative research 101 physician
members at 15 medical schools from the United States
Questionnaires Demand own care
Manipulative
Other patient behaviors Whiner
Unfocused
ER abuser
Family conflict
Hidden agenda
Excessively
complimentary
Slow talkers
Lack of adequate experience among the physicians Exposure to different patient situations
Shakaib U. Rehman Expanding Our Skills for Dealing With
Difficult Patient Encounter
2006 How can you be more effective in dealing with
difficult patient situations?
Qualitative research 40 doctors from South Carolina Questionnaires is hostile or angry
doesn’t follow instructions
is too demanding or needydoesn’t know how to describe
his symptoms

asks too many questions

Difficulty in interacting with patients Many medical practitioners were interviewed

Evidence-Based Tools: Review Matrix

The Professional Factor

In any difficult patient-physician association, the patient usually holds a divergent view to that of the physician. Patients also complain of dealing with a ‘difficult’ physician. This makes the patients to be reluctant to share information, and they start displaying unconstructive feelings towards the health practitioner. It has been established that physicians with fewer experience, lower job fulfillment and poorer psychosocial feelings have more difficult patient encounters (Perez-Lopez, 2010). This is the situation experienced by most young health professionals as they start their careers due to, poor working conditions, work overload and a high number of difficult cases. The untested physicians may be considered as difficult professionals especially when they come across patients with unclear symptoms and complaints that carry on even after treatment, or failed clinical management (Short, 1994). The patients receiving inadequate treatment or feeling ignored, will become frequent visitors and this will cause friction in the patient-physician association. In such circumstances, the physician is yet to recognize the emotional background and the personal needs of the patient (Perez-Lopez, 2010). The difficulty on the physician’s part may also stem from his work style and belief system, character and behavior of the patient, cultural gaps between the physician and the patient and other external factors affecting the encounter (Smith, 1997).

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Rehman and Johnson, as part of their studies, asked patients what behaviors in their doctors they find most difficult to deal with, and the responses were as follows. Majority felt the doctors are too rushed (30%), are too hard to get hold of (19%) and they speak too technically (11%). Others complained of doctors being too arrogant and not giving enough guidance. Majority of doctors interviewed under the same study agreed that their different character traits either helped or hindered the encounter with a difficult patient. There were a small percentage of doctors who believed that their character has nothing to do with the fact that some patients are considered difficult. Some of the traits identified as contributing to making the encounter harder for doctors included personal anxieties, being overly judgmental or critical, having a defensive personality and being too sympathetic to patients. The helpful traits in physicians ease the physician-patient encounter include; being comfortable at work, being open, having tolerance and patience, a strong empathic ability and ability to interact and learn from others (Rehman & Johnson, 2006).

How to improve physician-patient relations

One positive outcome from all these experiments is that the health practitioners do not think of disowning the difficult patients, but instead try to find solutions to improve relations to avoid the difficult medical encounter. There has to be effective communication. This can go a long way to improve the relationship between the doctor and their patients. The most successful strategy to apply is the use of compassion. Demonstration of compassion towards the patient during the encounter makes them feel understood and enables the encounter flow freely. The health practitioner should also listen attentively to the patient without being judgmental (Anne, Rabatin, Manwell et al, 2009). The physician should show patience as he listens to everything the patient has to say. This makes the patient feel that he or she is being taken sincerely. This will make them more cooperative, and they are likely to open up more. In a situation where the physician is expecting a difficult patient, he should establish a clear construction for the encounter by forecasting ahead of time. Part of this involves having a set time frame for the encounter and outlining what to expect once the patient arrives (Groves, 1978). The physician should concentrate on the most urgent problem during the patient’s visit. The patient may come with a long list of complains which the physician should allow him or her to outline. However, the doctor should also remind the patient that they have limited time together, so they should focus on the most crucial issues. If the patient still has more to talk about, he or she can be booked for another appointment later. Patients will get a clear understanding of their illnesses and ailments if the doctor uses easily understandable language to communicate with the patient. This also helps the doctor take charge of the encounter so that he runs things accordingly (Groves, 1978)

How to manage communication problems

Even with all the technological advances in the field of medicine, good patient-physician communication is still extremely vital in any clinical scenery. The way the physician communicates with the patient will have a bearing on patient satisfaction and influence the patient’s compliance to medical suggestions (Klein, 1982). The physician should always aim to earn the trust of the patient as a way of preventing difficult clinical encounters. Physicians must also learn how to exercise self-control as a way of neutralizing the emotional reactions coming from the difficult patient. There are cases in which the patient may exhibit symptoms of depression or maladjustment to life problems. In such situations, the physician should assess the symptoms carefully while bearing in mind that a patient’s negative emotional reaction to a physician may be as a result of a personality disorder (Kirmayer, 2004). When dealing with difficult patients with undiagnosed or natural conditions, the physician use open questions so as to invite the patient to talk about the problem the way he or she perceives it. There are also notable questionnaires that have been designed to help identify patients with sub-clinical psychiatric problems (Spitzer, 1999). Many patients who present with unexplainable symptoms tend to have underlying psychiatric problems and, therefore, require unique management.

Conclusion

It has been established through psychological research that healthcare professionals need to be trained in sincerity and emotional detection so that they are able to express genuine interest in patients’ complaints (Federman, 2001). For a physician to manage a difficult patient, empathy, attentive listening and discussion are extremely influential. The physician must learn how to apply patient-tailored communication skills like empathy, tolerance and nonjudgmental listening (Rehman & Johnson, 2006). Difficult patients need to be treated well, and the medical providers should always try to educate the patients more on their illnesses. Physicians who have problems dealing with difficult patients can always seek help from experienced colleagues and psychiatrists. When the physician succeeds in establishing meaningful communication with the patient, there will be general agreement on the diagnosis between the two. This will make it easy for the physician to get informed consent from the patient, who will also be willing to follow the treatment prescribed. This results in optimistic healthiness outcomes and mutual satisfaction between the two parties (Rehman & Johnson, 2006). The doctor should resolve his own contribution to the conflict and learn how to deal with the patient. This helps to solve any difficult encounters with the patient. There are support groups dealing with these issues, which he can join and share experiences with other colleagues facing the same problems. These support groups help the physician in understanding the difficult patient, and help him improve the difficult physician-patient encounter.

References

Anne, P.G., Rabatin, J.S., Manwell, L.B., et al. (2009). Burden of difficult encounters in primary care: data from the minimizing error, maximizing outcomes study. Arch Intern Med, 169, 410.

Federman, D., Cook, F., & Phillips, S. (2001). Intention to Discontinue Care among Primary Care Patients: Influence of Physician Behavior and Process of Care. J Gen Intern Med, 16, 668–674.

Groves, J.E. (1978).Taking care of the hateful patient. New England Journal of Medicine, 298, 883–887.

Kirmayer, J., Groleau, D., Looper J., & Dominice Dao, M. (2004). Explaining medically unexplained symptoms. Canadian Journal of Psychiatry, 49, 663–672.

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Klein, D., Najman, J., & Kohrman, F. (1982). Patients’ characteristics that elicit negative responses from family physicians. Journal of Family Practitioners, 14, 881– 888.

Perez-Lopez, F. (2010). Difficult (“heartsink”) patients and clinical communication difficulties: Patient Intelligence, 3, 1-9.

Rehman, S., & Johnson, S. (1994). Expanding Our Skills for Dealing with Difficult Patients. British Journal of Hospital Medicine, 51, 128130.

Rosenfield, J., & Jones, L. (2004). Striking a Balance: Training Medical Students to Provide Empathetic Care. Med Educ, 38, 927–933.

Smith, S. (1997). Dealing with the ‘difficult’ patient. In Hind CRK (Eds.) Communication Skills in Medicine (101–114). London: BMJ Publishing Group.

Spitzer, L., Kroenke, K., & Williams, B. (1999). Validation and utility of a self report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA, 282, 1737–1744.

Steinmertz, D., & Tabenkin, H. (2001).The ‘difficult patient’ as Perceived by Family Physicians. Family Practice, 18, 495–500.

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