Treat challenging patients with understanding, respect

Be aware of why they're acting that way

Every case manager encounters challenging patients and family members — those who are angry, provocative, depressed, or just plain ornery. That's because people in the hospital are sick, under stress, and often fearful about their situation.

"There is a huge difference between difficult people and people who are acting in difficult ways because of difficult circumstances. People don't wake up in the morning and say 'My job for today is to be a problem for my case manager,'" says Tammy Lenski, EdD, chief executive officer of Tammy Lenski LLC, a conflict resolution and negotiation consulting firm based in Peterborough, NH. (For more about avoiding mistakes with patients, see related story, below.)

Most challenging patients are otherwise decent people who are having a bad day, week, or month, says John Banja, PhD, professor of rehabilitation medicine, medical ethicist at Emory University's Center for Ethics and director of the Section on Ethics in Research at Emory's Atlanta Clinical and Translational Science Institute. Their ways of coping with distressful events were shaped long ago. "Challenging patients don't think they are being difficult," he says. "They're feeling overwhelmed, helpless, and depressed because of their situation, and they project their feelings to those around them." (For more information on difficult patients, see related story,below.)

Case managers often deal with patients and family members who are under stress and might be difficult to deal with, Banja adds. It's important not to take it personally but to keep in mind that the patient or family member is simply trying to share his or her overall mood and the feeling that what happened is unfair, he says.

Case managers are in the unique position of being a link between the patient and the treatment team, says Kathleen Miodonski, RN, BSN, CMAC, manager for The Camden Group, a national healthcare consulting firm with headquarters in Los Angeles. "Case managers often can diffuse problems between the treatment team and the patient and family members. They aren't doing the hands-on care, so they have more objectivity," she says.

Be aware of which patients might become difficult, and make it a point to develop a rapport with them, Miodonski advises. For example, if you hear other staff talking about difficult patients, it might be a cue for you to talk to the patient and call in other people, such as a social worker, or a representative from the patient's religious or cultural organization. "Case managers may not be involved with every patient, but sometimes simple cases can be more difficult. It's the case manager's role as patient advocate to step in when there are problems," she says.

Banja suggests that when case managers work with sick people, they should present themselves as supporters and encourage the patients to share their frustrations, disappointments, and pain. "The biggest mistake we make is emotionally reacting to patients, instead of trying to understand why they are acting that way," he says.

The therapeutic approach to dealing with challenging patients is to try to understand the patient's behavior as a reaction to his or her circumstances and to discover what is making them difficult, he says. For example, if patients have had a bad experience with a healthcare professional in the past, they might not believe or trust you. Encourage patients to talk about their past. This talking might explain why the patient is being difficult, and once you understand it, it will be easier to cope with. "If you can get patients to start thinking about why they are feeling the way they are and expressing it, it might defuse the feelings and put you on the way to a better relationship," he says.

Begin by validating the patient's feelings by saying something such as "Mr. Jones, you seem to be very angry. Please tell me what is going on." Then, be a good listener. Don't talk, except to intersperse comments such as "I hear you," or "That sounds like an important point. Tell me more." Try to obtain insight into what it is like to be Mr. Jones right now.

Sometimes, the best you can do is to keep a difficult encounter from getting worse, he says. You might think at the end of the discussion that it went poorly; however, remember that you're likely to have another conversation with the patient, and it probably will go better.

Lenski advises that healthcare professionals resist the temptation to run or to fight when they encounter grumpy or combative patients. "Leaving the room or arguing with patients tends to escalate the situation, and that will only make it worse in the future," she says.

When patients yell or snap at you, resist the temptation to push back. Instead, take a deep breath and remember that there is a huge difference between yelling at somebody and yelling toward somebody, she says. "Most people in the hospital setting are not combative because they don't like the person with whom they are dealing." Lenski points out. They're acting that way because they are on edge, frustrated with several things, and everything seems to be a major struggle.

"When people realize that the combative patient is yelling toward them and not at them, it helps them understand that the person yelling is actually expressing frustration and pain. Then the healthcare professional can have compassion for the patient's misery," she says.

If the situation escalates, Lenski advises taking a break. Tell the patient you feel like the conversation got off on the wrong foot and you're going to come back in 30 minutes and start over, she says. "If you stay in a hot conversation, it doesn't get any cooler. It's better to take a half hour break and do something to take your mind off the topic," she says.


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Don't let patients get you down

Don't fight back in tense situations

Dealing with difficult or challenging patients makes healthcare professional feel uncomfortable, whether the patients are angry, depressed, provocative, or just plain cranky, says John Banja, PhD, professor of rehabilitation medicine, medical ethicist at Emory University's Center for Ethics and director of the Section on Ethics in Research at Emory's Atlanta Clinical and Translational Science Institute

"The first human response when people feel uncomfortable is to defend themselves, rather than trying to understand what is going on with the patient. With difficult patients — and remember, we are the ones who call them 'difficult' — this is probably the wrong thing to do, and it's probably why relationships between these kinds of patients and healthcare professionals don't tend to improve very much," he says.

Case managers need to expect that they're frequently going to encounter difficult patients and should keep their emotional health in good shape, Banja advises. "Remember that you can get along fine with some patients, and others know how to provoke you. Patients are labeled 'difficult' because they assault healthcare providers' self-esteem and make them feel out of control, incompetent, and inadequate," he says.

Confront your own fears, anxieties, fantasies, and insecurities. The psychological baggage that you've been carrying around since childhood will come out when you are made anxious by difficult patients, Banja says. Acknowledge to yourself that your own insecurities might create a need to be appreciated, loved, and admired and that difficult patients might trigger these insecurities. "Healthcare professionals should acknowledge that difficult patients are a very real problem and that dealing with them can cause burnout," he says. Look for opportunities to educate yourself and develop a good skill set to cope with these patients.

Banja recommends that training programs for case managers include information on how to cope with difficult patients. "You can't know too much about how to empathically engage these patients," he says. (See recommended reading list at end of this story.)

Evaluating a case manager's ability to cope with difficult situations should be part of the hiring process, he says. "It's a huge mistake to hire a case manager based only on their intellectual ability. They need to be able to cope with all the difficulties they are going to encounter. Someone who understands clinical medicine very well may not be able to negotiate a difficult relationship," he adds. The person doing the hiring should have some experience in communication skills in order to evaluate the answers, Banja says. Ask prospective employees to describe how they would deal with a difficult situation. Ask them if they have mental health experience, how they feel about working with difficult patients, and what they know about empathy. "If a case manager says 'I expect a client to work with me completely and respect my authority.' I wouldn't think his or her empathetic skills were very good," he adds.

Recommended Reading:

  • "Empathy in Patient Care: Antecedents, Development, Measurement, and Outcomes" by Mohammadreza Hojat, PhD, Springer, 2007.
  • "Find Your Focus Zone: An Effective New Plan to Defeat Distraction and Overload" by Lucy Jo Palladino, PhD, Free Press, 2007.
  • "From Detached Concern to Empathy: Humanizing Medical Practice" by Jodi Halpern, MD, PhD, Oxford University Press, 2001.
  • "Making Mediation Your Day Job" by Tammy Lenski, PhD, iUniverse, 2008.
  • "Medical Errors and Medical Narcissism" by John Banja, PhD, Jones and Bartlett, 2005.
  • "Zen of Listening: Mindful Communication in the Age of Distraction" by Rebecca Z. Shafir, MA, CCC, Quest Books, 2003.

Avoid making mistakes when dealing with patients

Don't set yourself up for difficulties

When healthcare professionals try to get patients to be cooperative and go along with the discharge plan, they often make four mistakes, according to Tammy Lenski, EdD, chief executive officer of Tammy Lenski LLC, a conflict resolution and negotiation consulting firm based in Peterborough, NH.

"If case managers make these mistakes when dealing with patients, they're setting themselves up for problems," she says. The mistakes are:

1. Assuming if people are given logical information, they will automatically follow your recommendations.

"We tend to think that if we give patients more information, they will change," Lenski says. "Instead, we need to try to understand why they won't do what you want them to. Maybe they lead a different life from what you imagine and they know that the treatment plan won't work for them."

When patients won't cooperate, stop giving then more and more information, Lenski advises. Instead, try to understand why they aren't cooperating and why they think your plan won't work. Don't interrogate the patient. Instead, say, "The discharge plan calls for X, Y, and Z but you won't do Z. What about Z isn't working in your life? Help me understand."

2. Assuming that nodding and silence means agreement.

Silence can mean a lot of things from "I'm thinking about it," to "I don't agree, but I'm never going to admit it," Lenski says. Patients might nod agreement because they believe that their agreement is what will get them out of the hospital, she points out. In some cultures, nodding has nothing to do with agreement, she adds.

Remember that the goal of the conversation isn't to get agreement, but to come up with a plan the patient will act on. Don't ask patients and/or family members if they understand, because they can understand the plan perfectly and still not follow it. Instead, ask them how the plan will work for them and what could get in the way of their following it.

For example, sometimes people who are overweight might not weigh themselves daily because they hate to know their weight. With heart failure patients who need to weigh themselves every day, Lenski suggests broaching the subject by saying something such as, "One of the things we know from experience is that patients who aren't happy with their weight often avoid the daily weigh-in, and the consequences can be dire. I am wondering if this might happen to you, and how I can help you get around it."

3. Letting their diagnosis of someone's personality flaws lead them when they work with patients.

"In a healthcare organization, people make diagnoses all the time, but there is a huge difference in diagnosing a medical condition and diagnosing a personality flaw," Lenski points out. If you label patients as uncooperative or difficult, you will start treating them in a different way, and that treatment is likely to compound the problem.

Case managers need to be aware that they let their tendency to diagnose patients extend into diagnosing personalities. The minute you start to think of someone as uncooperative, stop and think that you could be wrong about the person. Remember that every person has family and friends who think he or she is just fine.

4. Trying to fix the person without understanding why they are being uncooperative.

Take time to talk with patients and understand them, Lenski says. People in the hospital setting are asked to multi-task and to move quickly, and they might think they don't have time to sit down and talk to their patients. But taking time on the front end to understand the patient might save time on the back end when the patient won't cooperate with the treatment plan or the discharge plan, she adds.