Difficult Patients

1
Difficult Patients
2
Difficult Patients

• Complain
• Unclean
• Uncooperative
• Extremely demanding
• Want to be waited on
• Socially unacceptable illnesses (STD, addictive
  disorders)

3
The Difficult Patient

• Disruptive
• Self-destructive
• Sexually harassing
• Aggressive or Violent

4
Factors that Lead to a Rise in Aggression

• Frustration
• Involuntary referral
• Discontent with treatment
• Pathology
• Schizophrenia w/ personality disorder
• Mania
• Environment
• Space
• Crowding
• Staff-patient ratios

5
Behavioral Phases of Violence

• Baseline or relative calm
• Pre-assault
• Abusive remarks or physical agitation
• Assault
• Out of control physical and verbal behavior
  implement crisis intervention protocol

6
Warning Signs

• Rapid, loud or profane speech
• Change in level of consciousness (e.g.
  disorientation or confusion)
• Clenched fists, gritting teeth, reddening face,
  widened eyes, flaring nostrils, rapid breathing
• Motor agitation pacing

7
More Warning Signs

• Visual or auditory hallucinations
• Sudden change in or extremes of affect (e.g.
  exhilaration, grandiosity)
• Sudden lack of affect in a previously very
  agitated or threatening person
• Use of alcohol or drugs

8
Management of Violence in the Workplace

• Prevention
• Treating patients and their families with respect
• Institutional security measures
• De-escalation Techniques

9
Prevention

• Dont use negative or derogatory labels.
• Try to change climate that devalues patient.
• Seek support and advice for dealing with
  difficult patients.
• Be aware of your emotional responses to patients.
• Affirm policies and practices that encourage
  respect.

10
Treating Patients with Respect

• Are patients and relatives given sufficient
  information to avoid feeling helpless?
• Could the environment be made more comfortable
  (e.g. waiting areas)?
• Do patients know how and to whom to complain?

11
Institutional Security Measures

• Make sure that areas are secure from people from
  the outside wandering around.
• Monitor areas that are isolated at specific times
  of the day or night.
• Keep walkways lit and free from hazards no
  blind corners.
• Provide a way for staff to raise an alarm to call
  for help, e.g. panic buttons, intercoms, cell
  phones.
• Train staff on what to do in a violent situation.

12
More Institutional Methods

• Arrange furniture and equipment so that staff
  wont be trapped.
• Make sure treatment rooms have two exits.

13
De-escalation Techniques

• First Make sure you have an escape route.
• Stay in an open, populated area
• Dont let the patient get between you and the
  door.
• Never turn your back on the patient.
• Dont crowd the patients personal space or try
  to touch him.
• Keep your own emotions under control and remember
  to breathe.

14
More De-escalation

• Dont try to talk while the patient is shouting.
• Do not
• Challenge or become defensive or confrontational
• Insult the patient
• Become judgmental or deny what is happening

15
More De-escalation

• Be genuine in your attempts to listen and affirm
  the persons feelings
• Let him express grievances, but respond
  selectively
• Speak in a normal tone of voice
• Communicate in simple sentences
• Show your concern
• Clear up misconceptions
• Acknowledge valid complaints
• Dont react to abusive statements
• Offer realistic solutions if appropriate.

16
More De-escalation

• Set limits calmly but firmly
• Call for back-up or security before the patients
  behavior escalates to violence
• Report all near-violent episodes dont blame
  yourself and try to hide it
• Broken windows theory tolerating lesser
  incidents results in increasingly violent
  behavior

17
Role-PlayingDifficult Cases