Chapter 15: De-Escalation of “Difficult” Patients

INTRODUCTION

Every nurse or healthcare provider has at one time or another encountered a “difficult” patient. There is no single definition of what constitutes difficult behavior, however. Indeed, the term difficult is used to describe a range of patients. These include the following:

• Indecisive patients. These patients take hours to make a decision and keep changing their mind.

• Complainers. These patients complain about everything at every opportunity, from the food, to the TV channel, to every aspect of their immediate care.

• Silent patients. These patients refuse to verbalize any of their problems, issues, or needs—bottling up their emotions until they finally explode in a torrent of rage.

• Aggressive patients. These patients are generally disagreeable or argumentative.

• Negativists. These patients do the opposite of any instructions received and refuse every care request, complicating their own care.

Regardless of whether a patient is indecisive, complaining, or some other form of difficult, all difficult patients have certain behaviors in common. For example, difficult patients often (Juliana et al., 1997):

• Demand special privileges that others do not receive

• Frequently make insulting remarks toward others

• Violate facility rules

• Act helpless

• Fail to cooperate with requests

• Play staff members against each other to cause tension among the team (known as staff-splitting)

• Fail to comply with treatment regimens

• Use threats rather than requests to get their needs met

• Hold up the flow of work by making unnecessary demands, complaining, or refusing to cooperate

Difficult patients often share certain characteristics, too—although with varying levels of intensity (Juliana et al., 1997; Wolf & Robinson-Smith, 2007). (See Table 15.1.)

De-escalating difficult patients can be a challenge—but it’s one that all nurses and other caregivers must meet. All human beings are worthy of respect, care, and compassion—even difficult patients. Besides, with patience and understanding, you might just convert that difficult patient into a dream charge.

ORIGINS OF DIFFICULT BEHAVIORS

Ultimately, patients exhibit difficult behavior for various reasons. Here are just a few possibilities:

• Pain or discomfort

• Stress or grief due to the loss of ...