Three effective ways to improve a difficult nurse-patient
1. Three fast and effective
ways to improve a difficult
nurse-patient relationship
Amy Luedtke
St. Catherine University
2. 1. Stop labeling patients and start
reframing situations
2. Use the NURS mnemonic
3. Prevent compassion fatigue and
burn out
Objectives – learn how to:
3. What is a difficult nurse-
patient relationship?
Hateful
patient
Demanding
Unappreciative
4. Stop labeling patients and start
reframing situations
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5. Use the NURS mnemonic
N - Name the patient’s emotions
U - Understand: provide empathy
R - Respect: Tell the patient something
you respect about them
S - Support: Ask how you can help
(Teo, Du, & Escobar, 2013)
6. Prevent compassion fatigue and burn
out
Talking a walk outside on breaks
Increase personal self-care behaviors outside of work
Install a bulletin board for motivational sayings, team and patient thank
yous
Get a massage
Eat healthy
Journaling
(Henry, 2013)
7. References
Breeze, J., & Repper, J. (1998). Struggling for control: The care experiences of 'difficult' patients in mental health services. Journal of
Advanced Nursing, 28(6), 1301-1311. doi:10.1046/j.1365-2648.1998.00842.x
Brunero, S., & Lamont, S. (2010). The 'difficult' nurse-patient relationship: development and evaluation of an e-learning package.
Contemporary Nurse: A Journal for the Australian Nursing Profession, 35(2), 136-146. doi:10.5172/conu.2010.35.2.136
Cunico, L., Sartori, R., Marognolli, O., & Meneghini, A. M. (2012). Developing empathy in nursing students: A cohort longitudinal study.
Journal of Clinical Nursing, 21(13/14), 2016-2025. doi:10.1111/j.1365-2702.2012.04105.x
Fiester, A. (2012). The “difficult” patient reconceived: An expanded moral mandate for clinical ethics. American Journal of Bioethics, 12(5),
2-7 6p. doi:10.1080/15265161.2012.665135
Groves, J. E. (1978). Taking care of the hateful patient. New England Journal of Medicine, 298, 883–887.
Haywood, Jr., C. (2013). Disrespectful care in the treatment of sickle cell disease requires more than ethics consultation. The American
Journal of Bioethics, 13(4), 12-14.
Henry, B. J. (2014). Nursing burnout interventions. Clinical Journal of Oncology Nursing, 18(2), 211-214. doi:10.1188/14.CJON.211-214
Horvath, A.O., & Luborsky, L. (1993). The role of the therapeutic alliance in psychotherapy. Journal of Consult Clinical Psychology 61:561–
573.
Martin, D.J., Garske, J.P., & Davis, M.K. (2000). Relation of the therapeutic alliance with outcome and other variables: a meta-analytic
review. Journal of Consult Clinical Psychology 68:438–450.
Potter, P., Desbields, T., & Rodriguez, S. (2013). Developing a systemic program for compassion fatigue. Nursing Administration Quarterly,
37(4), 326-332. doi:dx.doi.org/10.1097NAQ.0b013e3182a2f9dd
Santamaria, N. (1995). The Difficult Patient Stress Scale: a new instrument to measure interpersonal stress in nursing. Australian Journal Of
Advanced Nursing, 13(2), 22-29.
Teo, A. R., Du, Y. B., & Escobar, J. I. (2013). How can we better manage difficult patient encounters? Journal of Family Practice, 62(8),
414-421.
Editor's Notes
Welcome to the presentation on three effective ways to improve a difficult nurse-patient relationship. Studies like Groves (1978), for example, explain that even just one difficult nurse-patient relationship can increase stress and compassion fatigue while decreasing job satisfaction for nurses. Several studies have shown that difficult nurse-patient relationships cause unnecessary stress and anxiety for the patient at best and can lead to stigmatization and a decrease in quality of care (Brunero & Lamont, 2010; Breeze & Repper, 1998). Difficult nurse-patient relationships cause negative effects for both nurses and patients alike, determining ways to strengthen the relationship behooves all involved.
The objectives of this presentation will be to teach Three fast and effective techniques to help improve difficult nurse-patient relationships. The techniques include
What is a difficult nurse-patient relationship? Until the last few years, previous research has placed continuous blame and shame on patients calling them difficult, noncompliant or non- adherent. Groves (1978) goes so far as to use the label “Hateful patient.” negative, demanding, aggressive, unappreciative, manipulative, pessimistic, and abrasive are all labels that help create a similar negative picture. The problem with these labels is that they don’t help fix anything or solve any issues. Three studies that show that merely labeling a patient as difficult creates a barrier that which in itself is a predictor of a more negative treatment outcome. Labeling a patient as difficult is a disservice to them and to the nurse. The relationship is originating in a hostile environment
(Brunero & Lamont, 2010; Horvath & Luborsky, 1993 and Martin, Garske, & Davis, 2000)
The first technique to improving a difficult nurse patient relationship is a cognitive behavioral change on the nurse’s part. Stop labeling the patient’s actions, instead reframe the situation more positively (Fiester, 2012). As cited by Fiester (2012), In one study up to 60% of patients were considered to be “difficult” and in another clinicians who scored lower empathy traits reported increased rates of difficult patients (Jackson and Kroenke 1999, as cited in Fiester 2012). Fiester (2012) argues that this is not usually a trait of the patient, rather a misconstrued reaction on the nurses behalf that the patient is being difficult.
The outcome of this study is that the behaviors being exhibited by patients are less objectively “difficult”
and more vulnerable to the “eye of the beholder” problem that may overstate or exacerbate those negative behaviors.
Fiester 2012 contends that Reframing the “difficult” patient as someone who perceives themselves as wronged in some way or believes they were treated unfairly or disrespectfully generates an ethical duty to address, validate, repair, or assist in making amends
For example, upon completing an assessment the nurse notices that the patient has no sequential compression devices in the room and asks the patient if she would like to utilize the devices to assist in treatment. The patient stated “No way, I hate those things.” Rather than the nurse labeling the patient as difficult, the nurse instead stated, “why do you hate them so much.” The patient stated they were too tight and itchy. Upon explaining to the patient that the devices were like Velcro blankets that use air to give the legs gentle massages to help with blood flow, the patient was excited to try them. This wasn’t a patient that was trying to be difficult, she just really didn’t like the feel of compression stockings. By reframing the patient as having a knowledge deficit rather than being difficult helps the nurse determine what the next intervention should be. Both the nurse and patient benefit from the reframing.
The next technique to improve difficult nurse patient relationships was researched by Teo, Du and Escobar (2013) who state that providing therapeutic communication can help facilitate the patient nurse relationship. For difficult relationships specifically, they suggest using the mnemonic NURS, N U R S to assist with difficult relationships.
The N in the mnemonic is to name the patient’s emotions. For example, if a patient is really upset about something, stating to the patient “that sounds frustrating or you seem very upset about that” validates the patient’s feelings and helps them know that you are listening to them.
The U in the nemonic is to understand or in other words, provide empathy. According to coon –ic -o, Sartori, Maro-nolli and Men – egh –nee (2012) and others empathetic nurses improve patient health. By consciously working on providing empathy, this will enhance empathic skills and assist in improving the relationship (Ozcan, O-flaz & Bakeer 2012). Haywood Jr, (2013) States that education of the sickle cell disease and a look at the life of someone with SCD is what is going to help increase respectful patient centered care treatment of scd. Research states that providing empathy and compassion rather than stereotypes is what is needed to provide high quality care to patients.
The R in the nemonic stands for respect. Tell the patient something you respect about them. It should be honest and sincere. Even something as simple as “I respect how difficult this must be for you” can be helpful.
Finally The S in the nemonic stands for support. Ask the patient what you can do to best help them.
The final technique for improving the patient nurse relationship is to prevent compassion fatigue and burn out. It is extremely difficult for the nurse to provide empathy and be caring when the nurse’s own needs are not met. Potter, Desbields, & Rodriguez (2013) state that self care is needed to decrease compassion fatigue and increase compassion satisfaction. If a nurse is suffering from compassion fatigue, the nurse patient relationship will be affected. Henry (2013) provides several possible interventions to decrease compassion fatigue and burn out. A few of the examples given were
We have learned from various studies the negative impact that difficult nurse-patient relationships have on both the nurse and patient. We have determined 3 quick and easy techniques to assist in improving the relationship. Further research to determine if these tools together are effective could further strengthen this presentation. Administering the Difficult Patient Stress Scale from Santamaria, 1995, before and after the presentation would be a great research project to determine the validity of this presentation. Thank you for your time and I hope you have found this presentation to be helpful.
