Why you want to work with the most difficult patient on the unit

I talked about the concept of "othering" and how I would work with this as a nurse or charge nurse on a unit to tighten our team and help us all work together better. The same concepts are true when I apply them to the patients.

First of all, think about the following two questions:

What does the "other"do poorly?

What does the "other" do well? 

Find me a "familiar face" or "frequent flier" and please - oh please - let them be a loud troublemaker! These are so frequently our folks who are misunderstood. Of course, the more loud someone gets, the more I wonder about their underlying motivation, but I usually assume it is some sort of fear. When this loudness is in process, be quiet, listen. You are looking for subtext. Hear the fear, worry, frustration or motivation.

When I hear the subtext, personally, I often find myself tell them how much it sucks or how difficult this all must be. I don't have to agree with them. I don't have to feel that way. I often know I wouldn't necessarily have reacted that way. I just have to hear how they feel at this moment that brought them to this place, and they need to feel that I hear them.

I operate on the precept that when someone is mad 1) you aren't teaching them anything and 2) they can only rage for so long. Acknowledging how difficult this can be for them shifts gears or at least puts their transmission in neutral. This is a great place to be. In neutral, they may need some more time to vent - but you are helping the patient feel heard. The more they feel heard, the more they'll be more likely to tell you the worries on their mind. Don't be surprised if it does or does not perfectly fit your clinical scenario or what you are trying to accomplish - humans aren't always rational but you have to hear this if you want to cease the disruptive behavior.

Next helpful hint: If you really want to de-escalate this quickly, you have to let someone have an easy way to escape the corner they've backed themselves into. A scared, worried, frustrated person can make a real ass of themselves. They can say some nasty stuff. Once they are less screamy and more listeny, my response goes something like this:

"Hey, you were just having a MOMENT. It doesn't define you. This is all pretty stressful and you were upset. Everyone has a MOMENT, including me at times. We're past it now. I don't take it personal. Now let's try to do something that gets us where you are trying to go."

Then I focus helping develop a mutual plan of action. Why? They are engaged and they are open to what we are doing and need to do. I am pretty candid about what we can't do too. Patients don't hear the limits of our treatments, systems or facilities enough, then clinicians wonder why the patients have these unrealistic expectations.  This candid explanation of the limits of the system helps patients be more reasonable - more patient.


Bonus skill: 
Once you learn to speak to what someone does well and what they do poorly you can improve your game with your patients who are as sweet as pie. Why? because pleasant demeanor merely means they haven't gotten sideways of you or everyone else. It does not mean they are having their needs met. They still may not have revealed their fears or frustrations to you. I have learned that actively seeking my patients strengths and weaknesses helps me prepare them in ways that set them up for success and not failure (e.g. no unexpected re-admits).