Tell your friends about this page!   On-Site Training Seminars Challenging Patient Situations Book Video Training Programs Healthcare Workplace Issues Ask Mary Rau-Foster's Advice Events Calendar Our Services Articles and White Papers Dealing with Challenging Patients About Us Contact Us Home     Want help on general workplace issues like conflict resolution, employee motivation and communication? Visit our sister site workplaceissues.com	Articles and White Papers Concerning Healthcare Workplace Issues   Dealing With the Challenging Patient by Mary Rau-Foster, RN BS ARM JD   Published in "Clinical Strategies, The American Kidney Fund Newsletter for Nephrology Professionals," Spring 1999   The topic of dealing with the challenging patient is one that is of interest and concern to the healthcare providers in the nephrology field. The definition or description of a patient who is challenging to deal with varies. However, the expression of frustration and a sense of hopelessness usually follow the description. Many patients express their frustration over having to be cared for and to interact with challenging employees. The answers to the question: "What are we supposed to do?" are neither simple nor easy. However, the answers do become easier when we step back and look at the dynamics of a dialysis unit, the patients who are cared for and the employees who are providing that care and attention.   "You take your patients as you find them." Our patients come from all walks of life, with different cultures, ethnicity, beliefs, values, educational backgrounds, support systems and communication styles. Many may have little or no support system at all and look to the dialysis staff to fulfill that role. Some of our patients have good overall coping skills while others have poor coping skills.   No two patients are the same, but all patients are alike in that their basic needs are the same. All human beings are motivated and driven to have certain common needs fulfilled. The needs that we all share are the basic needs of survival, safety and security followed by the need to be loved, to belong to a group, to be respected and to achieve self-actualization.   "Familiarity breeds contempt" Any ongoing relationship is subject to conflict, strife or disagreement. The dialysis facility can be fertile ground for conflict. The relationships by and between the staff and the patients are complex because of the chronicity of the illness and the frequent contact that occurs with the thrice-weekly dialysis regimen. In addition, the dependency of the patient upon the healthcare provider may bring about conflicting feelings of need and resentment because of that dependency.   "Whose life is it, anyway?" The role of the dialysis caregiver is to educate, counsel and support the dialysis patient. We must refrain from being personally offended when our advice and counsel is not heeded. We also must avoid acting, or being perceived as acting, in a parental role. Our responsibility is to relate to the patient on an adult to adult level.   "Good fences make good neighbors." Boundaries are a necessity in any relationship (including the professional one) if the relationship is to be healthy and fulfilling. Boundaries come in the form of written policies and procedures, or they can be communicated verbally and by physical actions. Patient rules and regulations identify some of the important boundaries that must be maintained at all times.   Any relationship (personal, professional or business) that is ongoing is subject to conflict. The old adage "familiarity breeds contempt" is applicable to the staff and patient.   The following are suggested steps for dealing with the challenging patient.   1.  Provide rules and regulations to each patient when he or she first begins their relationship with your facility. Provide explanations and reasons for the rules and regulations and give the patient the opportunity to ask questions about them. Remind the patient of the rules when he or she fails to follow them.   2.  Provide staff education and counseling. Providing the staff the opportunity to express their frustrations and concerns at the appropriate time and place is a necessary step in helping the patient. In addition, provide the employees with guidance and training in how to deal with and effectively communicate with patients who are being difficult.   3.   Address concerns before they become problems. The Medicare Conditions of Participation requires that there is a grievance mechanism in place to allow the patients to express any concerns or problems which he or she may encounter. In addition, it is important to create an environment where the patient does not fear retaliation for exercising this right.   4.   Attempt to determine the nature, the contributing factors and possible solutions to the problems encountered with the challenging patient. This involves interviewing the patient to determine why he or she may be acting in a disruptive or difficult manner.   5.   Clarify expectations with explanations. If there is an expectation that the patient needs to change certain behaviors or to refrain from acting in a manner that is not conducive or appropriate for the environment, an explanation of what is expected of the patient is necessary. The focus should be on the behavior and not on the patient's personality.   6.  Confront and counsel "one on one" with patient. Select an appropriate time and place where the counseling session could take place. The focus of the counseling session should be on the behavior(s) that needs to be changed.   7.   Develop a plan of action with staff and patient input. The focus should be on how we might assist the patient in making the needed changes. Getting the patient's input regarding the cause of and solutions for the disruptive behavior may increase the likelihood of a successful outcome.   8.   Group counseling with the patient. It is important that certain members of the staff be present when the group counseling session takes place (Medical Director, Administrator, Nurse Manager, Social Worker). The purpose and mechanics of the meeting should be planned out in advance. This meeting should focus on problem issues and what steps need to be taken to correct the problems. Care should be taken to create an environment conducive to problem identification and resolution, and not one of intimidation.   9.  Document all steps taken with the patient and staff regarding the nature and context of the conflict. Be factual, objective and specific in the documentation of any counseling sessions with the patient.   10.  A contract that outlines what behavioral changes are necessary in order to continue the relationship, may be an effective tool to use with some patients. This agreement should be specific and applicable to that patient and to his or her disruptive or difficult behaviors. It should not only address what is expected of the patient, but the agreement should also identify what the patient can expect from us, as healthcare providers.   11.  Termination of the relationship with a patient should occur only as a last resort and when all other options have been exhausted. Prior to taking this final step, the ESRD Network should be made aware of the situation and the steps you have taken. In addition, it is important to remember that a facility can not terminate a relationship with a patient solely because the patient is not being compliant with his or her treatment prescription. However, the patient's nephrologist may terminate his or her relationship with the patient because of non-compliance. The patient's relationship with the facility would also terminate at the same time if there are no other physicians on staff at the facility who are willing to accept the patient as a client.   If the termination becomes necessary, the patient must be given adequate notice of the last date of treatment (such as thirty (30) days) and must be provided with a list of other dialysis providers and physicians in the geographical area.   In conclusion, being a dialysis patient or the provider of care to the dialysis patient can be difficult. As healthcare professionals charged with the responsibility of providing life saving treatments to persons whose lives have been disrupted by this illness, we must remember to be compassionate and understanding. This requires stepping back mentally and emotionally and viewing the patients from a different angle. It includes reviewing our expectations of the patients and how they should respond to the stresses of their lives. It also begs that the following question be pondered . . . "What kind of dialysis patient would I be?"     About the Author Mary Rau-Foster, President of Foster Seminars and Communications is the author of a book entitled "Dealing with Challenging Dialysis Patient Situations." She has also written and produced a video based training program on this same topic. In addition, she is a nationally known speaker on this topic. For more information, contact Mary.   © 1999-2000 Mary Rau-Foster. Reprinted by permission of American Kidney Fund.       More Articles and White Papers   Mary Rau-Foster, RN BS ARM JD     “Being a dialysis patient or the provider of care to the dialysis patient can be difficult. As healthcare professionals charged with the responsibility of providing life saving treatments to persons whose lives have been disrupted by this illness, we must remember to be compassionate and understanding.”
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