Crucial Conversations with a difficult patient

Crucial Conversations with a Difficult Patients

    Working on the Burn/Trauma surgical unit, we are faced with a diverse population of adult patients that have experienced a variety of traumas.  Patients are faced not only with life altering traumas, but are thrown into a completely new structured environment where they have very little control over their daily routine. The majority of our patient’s were independent with activities of daily living (ADL) from a variety of racial and ethnic backgrounds; many of them lived risky lifestyles prior to the trauma.  Patient’s suffer from loss of control in their life due to the sudden paradigm shift from being independent to dependent: relying on nurses to reposition in bed, assistance in transferring to a chair, help getting washed or going to the bathroom, bedpans, and dressings changes. As nurses, we try our best to support this loss of control patients feel, but many times patient’s act out or lash out in anger causing emotional strain on our staff. Advocacy is an integral part of our professional role.  We Advocate for ourselves, for our patients, for our colleagues, and for our profession across continuum of employment settings and roles (Tomajan, 2012).  When dealing with a difficult patient, it can be challenging to find that voice to not only advocate for your self, but for that patient as well.  Crucial conversations with a difficult patient can be frustrating to say the least.

Below are some helpful tips on how to resolve conflict with difficult patients (Guiliana, 2006):

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• Body language: Be aware of what your body is saying, body language can reflect what your mind is thinking, not the words you are saying
• Eye contact: Make eye contact and show your interest!  When you fail to make eye contact, it leaves room for patients to question their importance, your truth, or your confidence.
• Mouth: When you are not speaking your mouth can give subtitle clues that can leave the patient wondering if you are holding something back.  Be sure to smile, even if you do not want to!
• Position of your head: Be sure to keep your head straight up, this will help you appear to be confident and authoritative.
• Arm placement: Do not cross your arms or fold then over your chest.  The patient may receive the wrong message and think that you don’t care or disagree with what they are saying.
• Movements: Try to control hand and leg movements, a lot of movement can demonstrate nervousness.  At the same time crossing your legs can look unprofessional and even interpreted as arrogant.
• Distance: Positioning your self too close or too far away can portray the wrong message.  Space can be tricky and difficult to get right.  Some patients feel standing too close you are trying to get into their face and others feel that too much distance represents that you are being rude or do not have time for them. The only advice I can give you here is to listen and look for clues from your patient to determine the appropriate distance.
• Speed and volume of your voice: If you talk really fast or loud it may make some patients escalade as well. As the conversation gets faster and louder, people often get carried away and say things that can be harmful or hurtful.  Slow, steady and soft should be your approach. For me, the louder a patient speaks the slower and softer I reply.
• How To Be Assertive: Assertive means taking control of the conversation, make your statement quick that the behavior was inappropriate then refocus the conversation back to the issue.  Be aware of your body language and again do not hesitate to get support from your leadership team, we are here to help. 
• Win-Win Scenario May Not Be Realistic:  It is not about who is the “winner” or “winning” the conversation, it is about resolving the issue.  Most people feel there has to be a “winner” in all situations, realistically there will probably be no winner.  Focus your energy on the resolving the problem.

Guiliana, J. V. (2006). How to resolve conflict with difficult patients.  Podiatry Today, 19(1) 76-82.  Retrieved from http://www.podiatrytoday.com/article/5033?page=3.

Tomajan, K. (2012). Advocating for nurses and nursing.  The Online Journal of Issues in Nursing, 17(1), 1-9. Retrieved from http://nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-17-2012/No1-Jan-2012/Advocating-for-Nurses.html.