A Nurses Guide: How to Deal with Difficult Patients

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Introduction

Being in the business of caring for people when they are at their worst means we often come face-to-face with patients amid emotional outbursts of anger. We can improve patient outcomes and our work-life satisfaction by putting the abilities to understand anger, learn and become aware of what goes on in others’ brains when they are upset, and adopt optimal techniques for handling these tough situations under our belt. Learning how to deal with difficult patients and being able to resolve conflict in a positive manner is one of the most valuable skills a nurse can possess. 

Consider Anger  

Depending on your personal life, you will likely have your own opinion about anger as an emotion. Generally, it does not feel good to experience it in ourselves, nor is it pleasant to be around others who are feeling this way. Becoming angry is a part of being human, and as a healthcare professional, we must learn more about it so we are aware of how to deal with difficult patients. Perhaps approaching this from a philosophical standpoint will further help us to see beyond our patient’s immediate anger and we can work to develop a plan to resolve the conflict. 

Anger as a Motivator  

First off, anger can be motivating. Oftentimes, when we perceive that there is a problem that is causing harm or injustice – whether it is affecting ourselves, a patient, the barista at the corner coffee shop, the planet, whatever – it is often anger that pushes us to act. As a very basic (and optimistic) example, a patient might be angry about being stuck in the hospital. Optimally, the experience will bother them enough to want to follow all of the steps their physician provides them so that they do not have to be readmitted. 

Catharsis 

For some, the act of being angry can be cathartic. For example, when we feel angry and begin to shout or slam a door, it is actually a way of releasing that built up, negative energy. Some people achieve catharsis and release their anger in productive ways, such as exercising, talking with a friend or therapist, journaling, or cleaning. Once you have completed the action and released the anger that you had, you slowly begin to calm down (1).  

If we don’t release this energy over long periods of time, it can unfortunately cause physical harm. Anger increases heart rate, blood pressure (think MI or CVA), blood sugar, and intraocular pressure; lowers our immune function and increases incidents of cancer; affects the digestive system; decreases bone density, and can be the cause of headaches and migraines. Being angry also negatively impacts our short-term memory as well as the ability to make rational decisions (2). Applying therapeutic techniques can be a beneficial method of how to deal with difficult patients, as this can provide the opportunity to help them release some of the pent-up emotion they have before it causes physical harm.  

Control 

When learning how to deal with difficult patients, we must consider the relationship anger has with control. When a person is in our care, there is undoubtedly at least one major thing going on with them that they cannot control; otherwise, they would be at home. Being in a hospital setting removes all of the controlled variables that the patient has been accustomed to from their daily life (i.e. foods, who they come in contact with and at what time, etc.) and a common response to this change is anger in an attempt to regain control of the situation (1).  

Stress & Trauma 

There is a strong correlation between people who carry a lot of anger inside of them and stressful life events, particularly childhood trauma such as neglect and physical abuse. There’s also an association between anger and psychiatric disorders such as bipolar disorder and borderline personality disorder. This is not surprising since many people with these and other psychiatric disorders experienced extreme stress and trauma in their youth (3).  

I find that keeping these tidbits of information about anger in mind helps me with how to deal with difficult patients and allows me to maintain my own composure. 

Explore Your Thoughts/Feelings/Opinions/Triggers 

Self-awareness is extremely important when learning how to deal with difficult patients. Allowing ourselves to be aware of our own experiences, feelings, and triggers because  can dictate how we respond to others in heated situations. For example, suppose you are someone who grew up in a household where you frequently experienced violence — in that case, you might respond in an unexpected, unhelpful, and unprofessional way when exposed to angry behavior from others, such as shouting back. On the flip side, perhaps you grew up in a household where there was little to no conflict and you are unsure of how to properly respond when someone behaves angrily towards you. Maybe you have been judged harshly for your feelings and/or resulting actions, and consequently, judge others the same in turn. 

Oftentimes we aren’t aware of our own tendencies until we step back and intentionally evaluate them. Considering your own experiences, thoughts, judgments, and things that trigger you can help you to become aware of why you react to situations the way that you do. You’ll then be more prepared to respond in a deliberate way when you next find yourself in a scenario with a disgruntled patient.  

Common Practice 

“Calm down!” and, “It’s not okay to yell!” yelled the nurse. We’ve all heard the countless ways healthcare professionals respond when figuring out how to deal with difficult patients who are angry. Maybe we have even found ourselves yelling similar statements as well, and that’s okay – we are all human, and being yelled at can be very triggering, Don‘t be too hard on yourself, evaluate how you should respond next time and prepare for it as best as you can because dealing with difficult patients is inevitable. 

Often, clinicians become triggered – in other words, we get angry or irritated ourselves when confronted with an angry patient. If we aren’t mindful of our own tendencies and subsequently give in to that trigger, we inadvertently make what’s going on with the patient about ourselves when the patient is the one who needs our care. How is it helpful if we become upset as well? When learning how to deal with difficult patients, keep in mind that by responding with anger or with words that are seeking to control, the patient will miss an opportunity to release their pent-up, intense energy which can result in physical harm. 

I am reminded of a time when my daughter was an infant. She always had a terrible time facing backward in her car seat. We were riding with a friend of mine and her six-year-old son when my daughter began to cry. The young boy covered his ears, saying, “Why does she have to be so loud?” My friend’s golden response was, “I know, honey, it’s no fun, but think how much worse it must be for her.”  

Even though this scenario is quite different from a healthcare environment, I think those same words whenever I hear one of my patients yelling or are upset about something. All I want to do is cover my ears, but by thinking of how much worse it must be for them, I’m able to avoid making it about me. 

Distraction 

Another common approach to dealing with difficult patients during an angry episode by utilizing distraction techniques. There are times when this application is going to be the best choice, particularly, when dealing with patients who are cognitively impaired (4). However, there are other instances where this technique may come off as insulting with otherwise oriented people and could exacerbate the issue. 

An example of an appropriate time to utilize this technique would be when dealing with a patient who has dementia and gets increasingly (and repeatedly) worked up over her belief that her loved one – who hasn’t seen the patient in recent history – is stealing from her. In this case, distraction might be the only way to calm her down. 

Giving Advice 

I work in a psychiatric setting, and when I was new to my position, I learned first–hand one technique that was not effective.  

A 40-year-old, physically tall and sturdy male patient became so upset that he started punching our walls. Staff intervened and ending up having to take him down to the carpet for everyone’s safety. Other than his increase in rate and depth of breathing, he was lying quietly, prone on the ground. I kept a safe distance and asked if he was alright: he didn’t respond. I wasn’t sure what to do or say. I was new, undoubtedly nervous, and hadn’t yet learned the value of what one of our psychiatrists refers to as “therapeutic silence.” I had learned in the past from my education and own personal experiences that breathing techniques were calming, so I tried saying, “it’s okay, just breathe.”   

Subsequently, he began yelling at me. He was saying not to tell him what to do, that he hated me, and to go away. By suggesting something to him in that intense moment, he took offense. If I’m honest with myself, if I were upset and someone had said something similar to me, it might not have gone over much better.  

Threatening  

Although this should only be used when absolutely necessary, nurses must be able to learn and understand how to deal with difficult patients through utilizing threatening tactics. Where I work, some patients simply live for the three smokes a day that they’re allowed. An example of this threatening tactic sounds something along the lines of, “if you don’t do what I say, you’re not going to get your cigarette.” Please note that this approach should not be utilized all the time, but in some cases, it can seem like the only way to get through to your difficult patients.  However, keep in mind that it is a way of trying to control the other person and is also a missed opportunity to increase trust between the patient and the nurse.

Benefits of Learning How to Deal with Difficult Patients When They are Angry 

As caregivers, we experience more job satisfaction when we can adequately learn to care for people who are angry. Imagine how rewarding it is to successfully manage situations and achieve positive outcomes for our patients that could’ve gone badly otherwise. Not only that but, we potentially run the risk of losing our jobs if we don’t learn this essential skill (see Case Study #2 below). Rapport increases when appropriately utilized techniques are applied in practice because they foster trust and show respect for what the patient has to say (8). 

For patients, these situations serve as great opportunities for them to release some of their anger. If we can be facilitators, assisting them to come to a more even-keeled place, they will undoubtedly experience better outcomes. Additionally, a situation involving a an angry patient can become dangerous quickly, so it is critical that we learn these skills for our own safety, and that of our patients. 

Anatomy Review 

The amygdalae are a couple of bunches of neurons found deep in each temporal lobe that play an important role in our emotions, including triggering the fight or flight response (5). The hypothalamus is near the base of the brain right under the thalamus, and is attached to the pituitary gland (6). Among many other things, it’s responsible for controlling the secretion of hormones from the pituitary gland, which is located behind the nose (7). Finally, our adrenal glands sit on top of our kidneys and put out different kinds of hormones, particularly, stress hormones (2). 

The Hormone Cascade 

Something triggers us (i.e. we’ve just sat down to chart, and the call light goes off for what seems like the hundredth time, and we haven’t eaten or used the bathroom all day). Our amygdalae, like canaries in a coal mine, sound the alarm by signaling the hypothalamus and release a corticotropin-releasing hormone — causing the pituitary gland to release adrenocorticotropic hormone. This chain of hormone releases tells the adrenals to drop big stress bombs: adrenaline, noradrenaline, and cortisol (2). 

When there’s too much cortisol, increased calcium is allowed to get into our neurons, which can end up leading them to die. Our prefrontal cortex (PFC) and hippocampus suffer the most from this unfortunate outcome. The function of the PFC becomes suppressed, which affects our ability to have good judgment. For example, saying something hurtful or that you do not mean to someone you care about during an argument. Following, when neurons die in the hippocampus, this is where our memories are stored. So if it’s not working well, our short-term memory and ability to store new ones are affected most (2).  

The presence of too much cortisol will also result in a lack of serotonin – the happiness neurotransmitter. With less serotonin, we feel more sensitive to pain, anger, increase in aggression, and more prone to depression (2).  

Consider every time you’ve ever tried to reason with a person who was already upset. How did it go? Did they immediately come to see the error of their ways? I can think of several occasions where a patient was so enraged about something that fixing whatever the issue was did nothing to quell the tirade. When trying to figure out how to deal with difficult patients, understanding what is going on in their brain during these episodes of rage can help us to make sense of it all and how to plan a deliberate, appropriate, and effective way to resolve the conflict.  

Tips for Handling Patients When They are Angry 

Beyond this lesson, you will find several publications that discuss in-depth how to manage de-escalation during potentially dangerous situations. De-escalation involves maintaining a calm demeanor and avoiding attempts to control the patient. As a result, they feel respected, and the trust between the two of you builds. Every person and situation is different, so a certain amount of intuition is also essential in order to creatively develop solutions (9). 

Safety First 

Since we now know that during escalated, angry situations, our patient’s brains are not exactly functioning at full capacity so try your best to expect the unexpected. One moment, a patient can seem like the calmest, and most collected person in the world — then they get triggered, and who knows what could happen?  

With this in mind, the first thing we always have to consider is safety – for ourselves, the patient, and others nearby. Here are some recommendations for keeping everyone as safe as possible: 

• Be aware of what’s around you and your patient. Are there things that could be thrown or used as a weapon? Do you wear necklaces or long earrings that can be pulled? 
• Always maintain a safe distance. If you don’t feel safe, get to safety. It’s okay to walk away from a situation if you feel that you are in danger, but never turn your back. 
• Bring a co-worker if you need to go into an angry patient’s room – never go alone. 
• Observe for signs of aggression. If your patient exhibits balled fists, getting too close to you, pacing, tense shoulders, glaring, tense jaw, facial flushing, shouting, or heavy breathing, be prepared.  
• Try to keep the area clear of others who might be put in danger or exacerbate the situation. This might be a challenge when you’re focused on engaging with your patient. However, it is helpful if you and your coworkers are all on the same page. Consider working with management to train everyone to be on alert for potentially dangerous situations with patients and their loved ones. 

What to Say vs. What Not to Say 

When I’m upset, the thing that helps me the most is feeling like I am being heard. For my patients, I have found that listening is one of the tactics that works best, but remember that in some instances, patients may have a hard time listening to others because they may become triggered. If that occurs, it can become difficult to maintain a calm demeanor that is necessary for de-escalating tense situations. If we can find a way to keep the focus on the other patient (who is coming to us with the issue), we can become better listeners and remain calm.  

Listening is a skill that not everyone excels in but it can make a huge difference when figuring out how to deal with difficult patients.   

Tips to improve listening skills: 

• Do not interrupt.
• Give your full attention rather than getting distracted by inner thoughts or environmental stimuli. 
• Repeat back what you’ve heard to affirm you got it right. 
• Ask related questions to show you’re concerned and want to deepen your understanding. 
• Convey a sense of empathy by using your body language, and making brief statements like, “That’s understandable.“ 

Since there is not a specific prescription or solution for dealing with all angry patients, we need to stay tuned and be creative to reach a mutually beneficial goal. By staying calm and truly listening, we’re better able to understand what is going on so that we can attempt to remedy whatever the problem is when the time is right. After listening, affirming, and giving the patient time to calm down, we can begin to work toward a solution. For example, I might say, “I hear that you’re upset about what happened, and that’s totally understandable. What can I do for you right now to help?” By approaching the situation this way, it affirms that I heard the patient, respect their feelings, and genuinely want to help them. When learning how to deal with difficult patients, this is an extremely valuable tool to possess.  

Additionally, body language is extremely important – it conveys so much! Simple adjustments like squaring ourselves to whomever we’re listening to and conveying accurate facial expressions depending on the situation ensures in the patient that we are giving them our full, undivided attention and that we truly care about what they’re saying.

Boundaries 

A word about maintaining boundaries; these are key! Just because I aim to listen and convey kindness actively does not mean that I am a pushover, and that my patients will get everything they want.  

For example, as nurses, we all know that we often don’t have the time (or energy) to have deep, confiding conversations with each and every patient. However, being kind can be done swiftly, and without caving to demands. A simple “no” can be said in a respectful manner. For example, we can briefly say in a kind tone, “I know it’s frustrating, and I get it, but unfortunately, I can’t talk with you right now because I’m in the middle of passing meds. Can we talk in half an hour or so?” 

There are also times when we have to set boundaries because we can see that we can’t do any good in that moment. I have a patient who shouts so loudly when she’s upset that I have to cover my ears for fear of damage! Sometimes she’s able to convey her feelings in a way that I can actively listen to, and these times seem to be helpful for her, but when she can’t, I give her boundaries. I say, “*Pema, I want to listen to you, but you’re hurting my ears.” If she’s unable to control her volume, I gently remove myself, stating, “I hear that you’re having a hard time, but I have sensitive ears, and your shouting is hurting them. Let’s talk later.” 

We all have to figure out where our boundaries lie. If you are someone who gets triggered by the angry behavior of others, you might do best to excuse yourself early on to catch your breath and ask someone else to help with the situation. If you are triggered, it’ll be tough for you to make the best decisions when figuring out how to deal with difficult patients.  

Not Taking Things Personally 

As nurses, I am sure we have all learned early on to not take anything personally, especially when dealing with difficult patients. In most cases, an angry patient yelling in your face will not be your fault. Remember, we are not responsible for other’s feelings and reactions; those are about them, not us. As we mentioned previously, we are all probably guilty of saying something that we didn’t mean when we were upset and we wish we would have given it a second thought, and in some scenarios, this could be the case. However, there are other instances where the angry behavior of a patient then results in them wanting to speak with your manager regardless of whatever the reason is being your fault or not.  

It’s helpful to recognize when a behavioral response is not in proportion to what actually happened because this can be a clue into possible long–standing issues. Of course, knowing all of this doesn’t mean we shouldn’t always do our best, but it can help us refrain from beating ourselves up too much when our best seems to fall short. 

Attempt to be aware of the things we have reviewed here so you can effectively handle and devise a solution on how to deal with difficult patients who are angry. Bear in mind how challenging it can be not to have control, especially during situations where we are unable to make rational decisions.

What to Do if You’re the One to Lose Your Cool 

As we discussed earlier, when we become triggered, our prefrontal cortexes (PFCs) don’t work properly, and that is when our decision–making becomes poor. The good news is that, since we know what’s going on in our brain, we can work on reactivating that precious (and potentially life–saving) PFC. At first, we might not be able to look at ourselves clearly until after an episode, but we can learn to recognize the signs of becoming triggered by examining what happened. Once we can do that in real–time, we can intentionally work toward becoming calm again.  

Take Care of Yourself 

Nurses are used to taking care of others all the time, but what about themselves? This is crucial. You must take care of and be kind to yourself. Our best is different every moment of every day, and that’s all just part of being human. Some days, we might be having a tough time, struggling with any number of things, just like our patients. Our temper might be shorter, our tone may be a little more on edge, but rather than judging ourselves too harshly, we should recognize our own humanity and just do our best.

Case Studies on How to Deal with Difficult Patients

Case Study #1

A 46-year-old female patient received an IM injection in her right glute this morning. It is afternoon shift change, and she is complaining that her right hip has been hurting since receiving this injection. She has repeatedly been approaching the nurse’s station about this issue. The off-going day shift nurse calls over his shoulder as he’s frantically attempting to finish documenting, “I’ve already assessed you, and I don’t see anything wrong. I talked to the doctor, and he ordered Ibuprofen which you received. I have let her know that you would like to speak with her; you’ll have to wait until she rounds next.”  

The patient begins yelling, stating, “None of you care about me! My doctor doesn’t care about me! Otherwise, she wouldn’t make me get these injections that hurt me!” The evening shift nurse arrives, sees that the patient she knew from the evening before is upset and that the off-going nurse is busy. The evening nurse steps behind the station desk so that there’s a barrier between her and the patient (in case she becomes more agitated and aggressive) and turns to face the patient with a concerned expression in place. “*Fiona, I see that you’re upset. How can I help?” The nurse listens, not interrupting the patient as she relays her issue. At a natural lull in the patient’s speech, the nurse responds, “It sounds like you’re frustrated about this situation. I get it; that’s totally understandable.” The patient goes on to express her feelings of not being cared for by the staff or the doctor, tearfully raising her voice. The nurse looks at the patient with concern and considers the possibility that this woman might have some history of not being cared for. She continues to listen as the patient goes on venting. Eventually, the patient shouts one last time, turns away, and stomps down the hall to her room. An hour later, she returns looking tired, a little embarrassed, but calm, and apologizes then thanks the nurse for listening. 

The above is based on an episode that I experienced about a year ago. This patient is still at the facility I work at, and I have not seen any such outbursts from her since. I can also attest to experiencing very good rapport with her since this event. 

Case Study #2

A 70-year-old male patient rings the call bell. The nurse answers and the patient shouts loud enough to be heard without the aid of the speaker, “Get over here! You people are useless! Because of you, I’m swimming in a puddle of my own urine.” The nurse responds, “Okay, but you don’t have to be so rude.” She slams the phone down, muttering expletives to herself. She takes her time, finishing up what she was working on, still ruminating over the patient, while he gets increasingly upset.  

She walks into the patient’s room, and she sees that he’s standing next to his bed, naked, leaning precariously on his IV pole. She says, “What are you doing? You’re going to fall.” The patient responds, “Well, you’re not doing your job!” “I shouldn’t have to deal with this,” the nurse mutters under her breath as she begins to gather the soiled sheets. The nurse, whose back is turned to the patient, doesn’t see that his face has gone the color of a bag of packed RBCs, his eyes are bulging, and his knuckles are white as they grip the IV pole. The patient attempts to use the pole as a weapon to hurt the nurse but ends up slipping on his urine-wet feet, striking his head against the wall, resulting in a concussion. He files an official complaint regarding the nurse, considers suing her for damages, and gets written up for the second time. Next time, she’ll be out of a job. 

Conclusion 

People get angry – it’s just a fact of our existence. Some, unfortunately, misbehave when they feel anger whether it’s out of frustration, stress, feelings of loss of control, or unmanaged old triggers coming to the surface. As nurses, we often have to figure out how to deal with difficult patients while being able to remain calm and composed. By understanding more about people who experience excessive anger and learning to apply the techniques discussed in this course, you will be able to form flexible and creative solutions that can result in making the best out of very challenging situations. 

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