Irritable Patient Behavior Affects Emergency Nursing Assessments
By Stacey Kusterbeck
Emotions run high in EDs — both for patients and for healthcare providers. “Despite this, very little is known about how these emotions influence clinical care,” says Linda M. Isbell, PhD, professor of psychology at the University of Massachusetts Amherst.
Isbell and colleagues wanted to gain insight on how patients’ emotionally evocative behaviors influence emergency nurses’ own emotions, assessments, advocacy, and handoffs. Did the presence (vs. absence) of patient mental illness influence these outcomes? The researchers conducted a study with 130 ED nurses from eight hospitals.1
First, nurses reviewed a medical record for four hypothetical cases. For each case, nurses watched a video of a nursing assessment of the “patient” who was seated on an exam table. In each case, the patient presented with symptoms corresponding to one of four diagnoses (myocardial infarction, adrenal insufficiency, malaria, and venous sinus thrombosis). Four versions of each case were created — with irritable patient behavior (e.g., demanding services or questioning the nurses’ expertise), with calm patient behavior, with mental illness present, and with mental illness absent.
“We wanted to identify situations where care quality may be at risk so we could identify and remedy factors before they compromise care,” says Kelly Gleason, PhD, RN, another study author and assistant professor at Johns Hopkins School of Nursing.
The nurses reported their emotions, recommended diagnostic tests, clinical assessments, and written handoffs. For patient encounters in which the patient exhibited irritable behavior, nurses reported more anger and unease. They also judged the patients as likely to exaggerate pain, as poorer historians, and less likely to cooperate and return to work and recover.
In their documentation, nurses were more likely to use negative descriptions of patients and more likely to omit information, such as whether tests were ordered.
For patient encounters during which the patient exhibited mental illness, nurses reported more unease and sadness. They were less likely to advocate for patients to receive diagnostic tests that were necessary to accurately diagnose the physical health concern.
“Mental illness is highly stigmatized in society, even among healthcare professionals, and is a source of negative emotions,” Isbell notes. “Individuals with mental illness do receive lower-quality care for their physical health complaints.”
However, in this study, the patient’s mental illness was somewhat subtle, appearing only in the electronic health records provided to participants and mentioned only once during the end of the nurse-patient encounter. “We anticipate that the effects in real-world EDs are likely to be much greater than those we observed in our experimental context,” Isbell predicts.
For ED nurses, providing high-quality care regardless of the presence of irritable behavior is an ongoing challenge. “It is hard not to have an emotional reaction in the face of irritable behavior, and the emotional reaction may affect decision-making,” Gleason warns.
Simply recognizing that irritable behavior is a risk factor for poor-quality care is an important first step. “Making a conscious effort to think through decisions, to ensure they are not biased because of the patient’s behavior, may go a long way,” Gleason offers.
System-level changes are needed to improve patient care and nurse well-being in EDs, according to Isbell. “Unfortunately, system change can be slow and difficult,” Isbell laments. “But efforts can be implemented within EDs to support reflexive practice, increased collaboration, and trust among providers — and may improve patient outcomes and provider well-being.”
1. Huff NR, Chimowitz H, DelPico MA, et al. The consequences of emotionally evocative patient behaviors on emergency nurses’ patient assessments and handoffs: An experimental study using simulated patient cases. Int J Nurs Stud 2023;143:104507.
For encounters during which the patient exhibited irritable behavior, nurses reported more anger and unease. They also judged the patients as likely to exaggerate pain, as poorer historians, and less likely to cooperate and return to work and recover. In their documentation, nurses were more likely to use negative descriptions of patients and more likely to omit information, such as whether tests were ordered.
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