One of the first nursing research studies I read was Felicity Stockwell's The Unpopular Patient (Stockwell, 1972), part of the early groundbreaking nursing research that began the shift towards evidence-based nursing. Stockwell's findings showed that nurses did identify some patients as ‘unpopular’ and challenged the readers to examine their interactions with patients and consider the reasons for such feelings. One particularly interesting finding was that unpopular patients were not avoided by the nursing staff, who often spent more time with them at the expense of the ‘uncomplaining’ patients who received less attention. In the 50 years since the work was carried out relatively little empirical research has gone on into the cause, management and effects on staff of those often referred to as ‘difficult patients’.
The danger of labels
Although I'm aware of the danger of labelling some patients as ‘difficult’—and that most people can be difficult given certain stressors and frustrations—nearly all clinical staff that I talk to have found some of their patients difficult in terms of their medical, social or mental health needs, and many have experienced verbal and at times physical abuse from patients. All too often the nurse accepts these difficulties and abuse and just carries on with their work. Verbal and physical abuse is most common in emergency departments and acute mental health settings, often fuelled by alcohol, frustration and fear, but is not uncommon in all other areas of nursing practice. It is triggered by many factors: pain, confusion, anxiety, frustration, fear, mental health problems and a variety of communication difficulties. It is important not to label patients, relatives and staff as ‘difficult’, but it is important to recognise and acknowledge that not all nurse–patient interactions are wonderful and life enhancing.
Recognising trigger factors
In a perfect world patients and their accompanying relatives would be greeted instantly on arrival by an experienced and qualified nurse, sat down in a quiet and comfortable room and assessed immediately. The doctor would be waiting to examine and order any investigations, which would be carried out immediately by experienced and qualified staff. A diagnosis would be made and treatment given, with immediate effects. Transport would be waiting to take the patient and relative home.
The nurse and doctor would then sit down and peacefully write up the notes and await the next patient. Sadly, this utopia does not exist, but anything that diverges from this ideal patient journey can act as a trigger factor generating poor communication, frustration, anxiety and anger. Some of these triggers can be lessened by good communication, changes in the physical environment, better staffing levels and staff training, but others are beyond the control of the clinical nurse, hospital or health service.
Working as a team
Teamwork, leadership and caring for each other form the most important sources of support for all nurses. If you take a few moments to reflect on the staff you work with then you will soon realise that some nurses are very good at caring for patients who have complex health needs, others are very good at caring for the more verbally aggressive patients, others still are good with the confused or anxious patients. Likewise, we each have weaknesses with particular medical conditions or behaviours. Teamwork is initially about using people's strengths whenever possible in terms of patient allocation, but it is also about recognising each other's weaknesses and helping people to develop their skills.
Surviving as a nurse
There are times for all nurses when they will be looking after patients who they find ‘difficult’ to care for. This may be due to the patient's age, medical condition, prognosis, personality or a variety of other factors. Whatever the reason, the nurse is left with feelings of frustration, anxiety, anger, guilt, helplessness or fear.
If you just accept and absorb these feeling, then they will drain you and, if accumulated over time, can lead to a reduction in your ability to care and eventual burnout. Most importantly, you must seek support from your colleagues and team leader; this can be either in developing skills to manage future situations, or just talking over how this one has made you feel. This is not a weakness in your ability to nurse and care. If you and the team can identify any factors that may have triggered the situation then as a team try to mange them in a positive way in the future. This may mean escalating the trigger factors or causes of the problems to more senior management.
Surviving as a caring profession
The relationship we have with our patients is central to the care and treatment they receive. We need to look honestly at that relationship, exploring the underlying factors that may prevent that relationship being a positive and life-enhancing one. This needs high-quality research that requires funding, an honesty to explore this difficult area and a willingness to act on its findings.