The ’difficult’ nurse patient relationship; development and evaluation of an e-learning package

Scott Brunero
Department of Liaison Mental Health Nursing, Prince of Wales Hospital, Randwick NSW

Scott Lamont
Clinical Nurse Consultant, Liaison Mental Health Nursing, Prince of Wales Hospital, Randwick NSW

PP: 136 - 146

Abstract

Nurses in most clinical settings experience difficult ‘nurse patient relationships ‘at various times. Attempts to describe and articulate how to manage such difficult relationships can be found, but often lay blame at the patient level and ultimately leave the nurse less confident to improve patient care. This study uses an action research approach in working with nurses in a generalist setting in developing an educational strategy that helped to improve their knowledge, skills and confidence in working within the ‘difficult nurse patient relationship' paradigm. Through the experiential style learning methodology of scenario based learning and applying this via e-learning, an effective educational approach has been developed. Using a quasi-experimental design to evaluate the e-learning package, significant increases in knowledge, skill, confidence and reduced nurse stress as measured on the ‘difficult patient stress scale' were shown. This approach allows nurses to reflect on their own behaviour and improve their ability to enhance patient care in difficult to manage nursing care situations.

Keywords

Nursing, Nurse patient relationship, difficult patients, mental health liaison

Article Text

Nurses frequently use the term ‘difficult' to describe a range of behaviours that patients demonstrate. Primarily these behaviours are associated with some level of refusal and non adherence to nursing care. Often referred to as the ‘difficult patient', it is a generally a term that encompasses a negative attitude solely toward the patient and even stigmatising the patient. Macdonald (2003) reports that nurses' inappropriately label patients whichcan lead to a global view of the patient which can compromise care. Given the very negative and one sided use of the term ‘difficult patient' and its disproportionate sense of blaming the patient the term ‘difficult nurse patient relationship' is used in this paper as to locate the behaviours displayed by both patient and nurse within a well defined area of the nursing literature (Mcdonald 2007; Stein-Parbury 2006; Laskowski 2001).

The term, ‘difficult patient' is used primarily within the literature to describe patients who display a range of difficult to manage behaviours. Typical behaviours reported include; self harm, aggressive, demanding, attention seeking, dependent, splitting, deceptive, manipulative and disinhibited behaviours (Sharrock & Happell 2001; Steinmiller 1999). The literature contains in-depth reports of patient behaviour within the nurse-patient relationship but is scant on discussing how the nurse behaves when responding to these behaviours. In some of the earliest work on the topic, Groves (1978) suggested that these types of behaviours in patients develop a sense of helplessness in the helper, a tendency toward unconscious punishment of the patient, confrontation with the patient and the patient being excluded from care. Stein-Parbury (2005) argues that a nurses' own thoughts, feelings and attitudes can affect how they approach a nurse patient relationship. Typically nurses may parallel some of the behaviours of the patient, demanding more from the patient, approaching in an apprehensive or aggressive manner. Nurses may also retreat and start to avoid the patient in the hope of the patients behaviour decreasing; unwittingly the patient then increases their behaviour to gain the nurses attention. Gallop, Lancee & Shugar (1993) argue that nursing staff report violence, self harm and treatment refusal as being associated with an inability to form a treatment alliance with the patient. Groves (1978) attempts to describe this group of patients as the ‘hateful patient', not patients where there is a simple personality clash but for patients for whom clinicians dread to be involved in a therapeutic relationship with. Groves (1978) categorises these patients as "dependent clingers, entitled demanders, manipulative help rejecters and self destructive deniers" but goes onto discuss how the emotions evoked in the clinician are directly relate to the behaviours of the patient. Whilst many of us behave within social norms whilst physically ill, some people may engage in behaviour that is not accepted as being socially desirable or behaviour that is not seen as acceptable by nursing and other health staff (Lamont & Brunero 2009).

Difficult behaviours are often associated with distressed or frequent users of health services, who often have mental health problems (Brunero et al 2007). Hahn et al (1996) in a prevalence study of this patient group found mental illness to be twice as likely in patients identified as difficult. Patients who have a history of mood disorders may often present with insomnia, back pain, headaches and fatigue in a search for explanations for their low mood. Patients with anxiety disorders may present with multiple physical symptoms with a focus on cardiac symptoms. Patients with alcoholism and borderline personality disorder may also present with somatic complaints (Hahn et al 2006; Haas et al 2005; Schafer & Nowlis 1998). Certain disordered personality traits can cause problems within the nurse-patient relationship. People with personality disorders may be excessively dependent, demanding, manipulative or non compliant with nursing care (Macdonald 2007; Haas et al 2005). Patient groups can also include those with chronic pain, complex care needs, substance abuse, chronic fatigue syndrome, obsessive-compulsive disorder, or addiction to anxiolytics and analgesics drugs (Robinsin-Wolf & Ronbinson-Smith 2007).

The literature on interventions is less concise with a range of nursing management strategies proposed. Chitty & Maynard (1986) discuss a model to understand the meaning of manipulation in nursing care, through a process of self awareness, Chitty & Maynard (1986) base nursing interventions on a model of understanding issues such as; trust, security autonomy and control. Carol & Orehowsky et al (1997) in an exploratory descriptive study using focus groups (n=53) of nurses, review nursing interventions for difficult to manage behaviours. The identifying themes of nursing practice included; getting the difficult patient label, difficult patient behaviours, reflecting on the label and passing it on, coping with a difficult patient, interventions that worked and interventions that did not work. Trimpey & Davidson (1998) and Nield-Anderson & Minarik (1999) suggest interventions such as; limit setting, understanding impulsivity, assertiveness, empathy, de-escalation techniques, maintaining consistency, avoiding power struggles and setting clear boundaries as effective nursing interventions.. Hay & Passik (2000) suggest a symptom focused model of managing people with personality disorders in medical settings, which include aggression management strategies, staff education and staff support. Limit setting of behaviours is also reported by Sharrock & Rickard (2002) to be effective. Within a generalist rehabilitation setting, Sharrock & Rickard (2002) developed guidelines which draw on the concepts of limit setting difficult behaviour within a humanistic framework. Huffman & Theodore et al (2003) in a case series study paper, argue for the use of dialectic behaviour therapy. There is clearly a development need for nurses to work in nurse patient relationships that pose some degree of interpersonal difficulties. Models on how to build the capacity of nurses working in generalist settings in developing their knowledge, skills and confidence in managing difficult nurse patient relationships need to be further understood.

Aim
The aim of this project was to develop an educational approach that engaged nurses in an experiential learning experience about difficult nurse patient relationships, and strategies for managing these.

Method
An action research approach underpinned the development of the project. Action research is a methodology where participants work collaboratively with a researcher to determine and enact solutions to research questions which confront them (Greenwood & Levin, 2005; Coghlan & Casey, 2001; Morton-Cooper 2000). Hall (2006) suggests that action research responds to the values and problems of key stakeholders which are likely to form the change required. Action research involves an iteration of cycles of assessment, planning, acting, observing, reflecting. During this study a number of iterations occurred and so are expressed within distinctive phases within this paper.

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