Uncool Customers
Nurses can allay fears of challenging patients with respectful, calm demeanor and personable contact

By Linda Childers
February 14, 2003

Peggy Szafranski, RN, walked into the patient's room in the intensive care unit feeling somewhat apprehensive. Her colleagues had described the cardiac patient she was about to visit as loud and uncooperative.

The man sitting in bed, a Giants baseball cap on his head, eyed her warily before returning his gaze to the National League playoffs on television.

"Has Barry Bonds been up to bat yet?" Szafranski asked.

Although the question had nothing to do with the man's condition, it had everything to do with gaining his trust. The two lapsed into friendly conversation about Bonds and the San Francisco team. After several minutes, Szafranski started an IV on the man, who gave her his full cooperation.

Nurses agree that difficult patients come with the territory in caring for the public. The odds for tense interactions have increased as the nursing shortage reduces the time nurses have available for patients.

Often, the contact that does occur is brief and can convey an impression that the nurse is rushed, which in turn fuels the negative feelings of already disgruntled patients.

Szafranski, who works as a crisis nurse at Stanford University Medical Center in Palo Alto, Calif., encounters a variety of challenging patients as she floats between nine acute care units.

"I've discovered that finding common ground with patients, giving them a little time to talk and then offering them some control of the situation can often work wonders," Szafranski said. In the case of the Giants fan, she established rapport and, after a brief chat, asked whether he would prefer to have the IV placed in his left or right arm.

"This patient was upset because he had tickets to a Giants playoff game, and instead of sitting in the stadium as planned, he was in a hospital bed with chest pains," Szafranski recalled. "It's a frightening experience to be in the ICU and, unfortunately, many patients take their fears and frustrations out on nurses."

While working in the hospital's emergency room, Szafranski has encountered a range of challenging patients-from the man who thought his ER visit would last only a matter of minutes to the elderly woman brought in by ambulance who lacked the transportation or funds to return home.

"When people sit in the ER for hours, it gives them more time to obsess," Szafranski said. "I've found that regularly updating patients, letting them know when their tests results will return or when the specialist is expected works well in reducing their fear."

Szafranski also relies on a team approach to assist her in many difficult situations.

"In one case, I had an elderly lady who was in tears because she was being discharged from the ER at midnight and was frightened because she had no way to return home," she said. "I knew that under certain circumstances, we could provide taxi vouchers to patients, so I contacted our social worker and reassured the patient that we would find her a way home."

Fear factor

The majority of difficult patients are motivated by fear, said Idora Silver, a national speaker from Reno, Nev., who frequently lectures on the topic of difficult patients and also serves as a consultant to medical malpractice insurance companies.

"When people are sick, they experience myriad fears, including fear of the unknown, their own mortality, possible out-of-pocket hospital costs and permanent disability," Silver said. "The key for nurses is to make the most of their brief encounter with patients and to attempt to address these fears."

Silver recalled a time when her own usually cheerful demeanor disappeared and she became the dreaded difficult patient. "I had a herniated disc that was very painful and I was terrified that I might need back surgery," Silver said. "Pain can make a rational person act horribly. In this case, the pain was everyone's fault but my own."

The nurse assigned to care for Silver became the target of her wrath. "Even though I was acting horribly, he continued to be pleasant," Silver said. "He made sure we had eye contact and he smiled and told me he knew how painful this must be for me. He took time to answer my questions and put me at ease."

The way nurses communicate with patients is far more important than the duration of the encounter, Silver said. "Research has shown that patients respond better when their nurses stand near them," Silver said. "It's also imperative to make direct eye contact, listen without interrupting and keep the conversation on track. If the patient starts to wander within the conversation, gently guide them back to the issue at hand."

Tone of voice is also critical when reassuring a disgruntled patient. Silver suggests speaking in a calming tone and avoiding any terse or sarcastic comments, even if the patient's attitude is trying.

Nonverbal communication is just as important as the spoken word, she said. In her frequent lectures to health care providers, Silver suggests trying to maintain a pleasant facial expression when faced with a difficult situation. "If you tell a patient everything is going to be fine and you're frowning or aloof, they can read into your expression and assume you aren't disclosing something about their condition," Silver said.

Giving patients time to vent their frustration and asking questions about their condition can also help dispel fears. "I encourage nurses to identify a patient's emotions and prompt them with questions," Silver said. "If the patient is scared, acknowledge their fear and ask them what they know about their condition. If a nurse is in a time crunch, they still can offer the patient handouts on their condition or referrals to classes, support groups or other resources."

If a workplace doesn't already have a resource file, Silver suggests starting one with photocopied handouts about diseases, medications, drug interactions, local classes and support groups and other community resources.

"Giving a patient written instructions is very important," Silver said. "It shows you care and also reduces the number of follow-up calls and repeat visits."

Knowledge is power

When Linda Scarberry, RN, meets with patients who have recently been diagnosed with renal disease, they often are angry and view their condition as a death sentence. "I begin by telling new patients some of my success stories, citing one woman in particular who has been on dialysis for 25 years, and another who started dialysis at the age of 89 and continues to do well," said Scarberry, a kidney patient educator for Baxter Healthcare in Kentucky and a former dialysis nurse.

Many disgruntled patients enter a medical setting upset and agitated as a result of a previous unpleasant encounter with a medical professional.

Scarberry recalls one patient, a young man who was deaf and mute, who, after meeting with his physician, became so frustrated that he declined dialysis treatment.

"Accompanied by a sign language interpreter, this patient met with his physician, who discussed the patient's condition using a lot of medical terminology that the translator wasn't able to convey to the patient," she said.

The patient's family later persuaded him to attend one of Scarberry's educational seminars for kidney patients.

"After the seminar, the young man gave me a hug. He said I answered his questions in simple terms and appreciated that I spoke to him directly."

For Scarberry, it's exactly the kind of encouragement she needs to keep smiling with all patients, pleasant or difficult.

Contact Linda Childers at eastbaypr@aol.com