When you decided to become a nurse, you knew it wouldn’t always be easy. You expected the long nights, the grueling shifts, the heartbreak of losing a patient. But something you probably didn’t think much about the possibility of not getting along with your patients. After all, you entered this profession because you wanted to care for your patients, not clash with them.
The fact is, though, that nursing means caring even when it’s hard. It means loving your patients even when you don’t like them. And that’s perhaps the most difficult and most important lesson that nursing school can never teach, the lesson that only your most challenging patients can teach. This article provides tangible strategies for new nurses dealing with difficult patients, without losing your sanity, your health, or your professional passion.
Seeing Through Your Patients’ Eyes
The first step to dealing with a difficult patient is to try to understand what’s causing their behavior. It’s highly unlikely that a patient is going to be difficult just for the fun of it. Chances are far greater that something has gone wrong and that’s fueling the problem.
Many patients’ behavior, for example, may be explained by their particular medical condition. Those with dementia, Alzheimer’s, end-stage renal disease (ESRD), or certain mental health disorders, may react aggressively, irrationally, or non-compliantly simply because their illnesses have impaired their ability to understand their circumstances or respond appropriately.
In addition to physical and mental health challenges, environmental and situational factors may also be driving your patients’ contrarian behaviors. Patients who have been recently diagnosed with a catastrophic or terminal illness may be grieving the loss of their health and function.
Or they may have experienced the loss of a loved one, the loss of a job, a divorce, or some other significant trauma that is causing them to be hyperreactive. Likewise, cultural and language differences may be limiting the patients’ ability to understand, ask questions, or express themselves effectively, and a frustrated patient is far more likely to act out in negative ways.
An important strategy for understanding your patients’ perspective is to practice active and empathetic listening. Ask questions and reflect your patients’ views back to them accurately and without judgment. This will not only ensure your own understanding, but will also reassure your patients that they’re being accepted, heard, and understood.
How to Respond
Once you have a better understanding of your patients’ perspective, you can then begin to formulate a response that is productive and beneficial to the patient and your relationship with them. But that’s going to require you to be self-reflective as well.
After all, nurses are only human, and there’s no such thing as complete, unimpeachable objectivity. Just as with your patients, your own responses may be influenced by factors that you’re not even aware of. We all have our own internal biases, not to mention the ordinary stressors of daily life, that may make us respond in inappropriate or ineffective ways to some patients.
Your patient, for example, might remind you of a contentious relationship in your own life, and you may project negative emotions regarding that person onto your patient. At the same time, if you are feeling overwhelmed by a particularly stressful day, you might find yourself feeling short-tempered, unsympathetic, and ready to lash out at any patient who adds yet more problems to your day. So, when you’re figuring out how to respond to a challenging patient, you have to determine, first, whether it’s the patient or whether it’s you and, above all, try not to take it personally.
Another key to managing difficult patients is to focus on de-escalation. That means focusing on remaining calm and non-defensive and, ideally, on allowing your patient to express themselves freely. This includes giving your patients a safe place to vent when needed.
De-escalation strategies can also be employed at the organizational level. For example, in the wake of the COVID-19 pandemic, health systems nationwide are facing significant reductions in revenues and staffing. That’s leading to a surge in patient wait times and perhaps unprecedented levels of stress on health care providers. Using hospital resource management strategies (HRM) can help your organization run more efficiently in the face of the current crisis and beyond. And that’s going to improve your patients’ experience and decrease your workplace stress.
Another important tool for dealing with tough patients is to help them become more educated about their condition and to feel more empowered to take charge of their health. One of the most significant stressors associated with a difficult diagnosis is the patients’ sense of lost autonomy.
Equipping patients with the resources they need to make informed decisions about their own lives, and their own care, can be a tremendous benefit in reducing negative behaviors. Mobile apps, for instance, can be used to help patients with their meal planning, lifestyle choices, and treatment plans. Connected patients can even access online communities reserved for other patients, their families, and health care providers.
The Takeaway
Nursing can be more rewarding than you ever dreamed. But it can also be more challenging than you ever imagined. The key to dealing with difficult patients, though, is to not take it personally, to focus on understanding the roots of their behavior and figuring out a response that is productive for and protective of you both.
With medical errors making national headlines, it is no secret that both training and experience are integral to success as a new nurse. Almost all nurses enter the field with a college degree, but recent research shows that novices make a large percentage of the errors caused by nurses. To avoid mistakes and build a strong foundation for your nursing career, here are three essential skills to prioritize during your first year as a nurse.
1) Developing Strong Instincts for Patient Safety
Patient safety is one of your primary responsibilities as a nurse. Safe medication administration is an imperative skill to master in your first year. You are the final check between the prescribing provider and the administration of a medication to the patient. If something feels “off”—maybe the dose seems too high based on doses you have given before or the medication doesn’t seem to fit your assessment of the patient—take a timeout and ensure the prescription is accurate. Mistakes happen even in computer-driven processes, whether a decimal point is missed, a duplicate therapy is accidentally prescribed, or a medication is placed in the wrong slot of a medication dispenser. Before giving any medication, ask yourself, “Are all of the correct pieces in place for me to give this medicine right now?”
Learning to safely calculate medication dosages goes far beyond a textbook. Learning tools like UWorld’s Clinical Med Math allow students to practice and perform dosage calculations without the risk of patient harm if they make a mistake. This tool is meant to be a hands-on resource to help students study for drug calculation exams during school, but it also provides fantastic experience to prepare you for real-world nursing.
Another major safety concern is patient falls. Precautions here may include rounding on older patients more frequently or enabling a bed alarm for high-fall risk patients. You should also utilize a mental checklist every time you walk into a patient’s room, such as:
Is the floor clear, especially the path to the bathroom?
Can the patient reach the call light?
Is the bed in the lowest position?
Adding these seemingly small things together develops a strong instinct for safety so when you enter a room, you automatically sense if something is out of place.
2) Forming Clinical Judgment
Your first year as a nurse builds clinical judgment on the foundation of all the knowledge you acquired in school. The ability to recognize potential or current complications that could cause harm is a strong asset to cultivate. This skill involves understanding the pathophysiology behind different disease processes and identifying the signs of improvement or decline. From there, the priority is determining the most important action you can take in the moment to ensure the best outcome for your patient. A textbook cannot teach you how to anticipate patient needs or develop clinical reasoning. You develop clinical judgment by applying your classroom knowledge to the actual patients in front of you.
As you refine your ability to assess patients and interpret clinical data, you reach the point where you can look at a patient and know something is not right—the monitors might look fine, but your assessment and instincts say otherwise. This is an important part of clinical judgment, and it is your job to dig deeper and advocate for your patients. Of course, this critical thinking must occur while also keeping up with scheduled medications at the same time that you are admitting a new patient and discharging another. Developing clinical judgment to juggle these moving pieces takes time.
3) Mastering Time Management
Time management is another key skill to learn in your first year of nursing. You should be able to look at your whole shift and plan a timeline based on medication schedules, planned procedures, and provider rounds. If all four of your patients have medications due at the same time, how do you organize your time so everyone receives their medications within an appropriate window? Many nurses have their own system of handwritten notes that they keep in their pocket to help organize their day. Asking to see your preceptor’s note system is a great way to get ideas during your clinical rotations in school or during the internship at your new job.
Structuring your day in the most efficient way possible helps develop a “clustered care” mindset where you complete a few tasks together so you don’t leave a room, only to return 15 minutes later. These organizational choices help you accomplish tasks in a seamless, resourceful way. The skill of effectively planning an entire shift comes with time. Do not be afraid to ask questions and learn from other nurses. Pay attention to colleagues who seem particularly organized and solicit their advice—even the smallest tip or trick can make your nursing practice stronger!
Working in health care can be emotionally demanding and stressful. Not only do nurses normalize their own emotional reactions to practice, but they also ease the fear and distress of their patients. Research shows that early career nurses are likely to react more negatively to the emotional demands of practice and are at higher risk of stress, emotional exhaustion, and burnout.
Emotional health is an important part of life. It allows us to work productively and cope with our daily job stress. Here are 5 tips to help new nurses manage the emotional demands of the job.
1. Take care of your physical health.
This is probably one of the most important ways to take care of both your body and mind. Your physical health can greatly affect your emotional health. Exercise regularly, eat healthy meals, and get enough sleep. Improving your physical health can positively impact your emotions on a large scale.
2. Focus on mastering your skills.
It is important that you focus on improving your ability to perform all nursing care and administrative skills independently. These skills will increase your confidence at work and promote satisfaction within your new role.
3. Practice resilience.
Resilience is the ability to overcome challenges quickly and effectively in order to move forward in life. Try to build positive beliefs in your abilities. Becoming more confident in your own abilities, including your ability to respond to and deal with new job environment, is a great way to build resilience for the future. Being resilient will increase your ability to perform under pressure and can affect the way that you view life and its challenges.
4. Practice deep breathing exercises.
Deep breathing exercises have been proven as an effective coping skill. They can help relieve emotional stress and anxiety on the job, improve your mood, and allow you to not to hold onto things that are out of your control.
5. Find a mentor or an experienced nurse who is a positive role model.
Having someone you can reach out to for guidance will help you properly manage the demands of your work and hopefully help you avoid burnout. Recognizing your emotions and expressing them properly can reduce emotional tension and emotional problems.
As a nurse, your day is spent with your patients and their information. You review patients’ records, listen to their health histories, administer medication, and engage in therapy. It is well-known for experienced nurses that all patient information is confidential and federally protected; however, new nurses often doubt how to maintain a patient’s privacy and confidentiality in an appropriate way.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Health Information Technology for Economic and Clinical Health (HITECH) Act established legal mechanisms to ensure privacy and security of medical identity and protected health information. HIPAA established security requirements for the exchange of certain health information and regulated its disclosure. HITECH magnified HIPAA to promote the implementation of electronic health records and supporting technology in the United States.
Nurses are obligated to protect confidential information about patients, unless required by law to disclose the information. Here are 7 key elements that new nurses must take seriously in order to prevent potentially disastrous violations.
1. Adhere to workplace security and privacy policies in protecting confidential patient information.
2. Understand and be compliant with HIPAA rules and regulations.
3. Understand the definition of individually identifiable health information, known as protected health information (PHI), and when it can be shared, how it can be shared, and with whom it can be shared. Examples of PHI covered by HIPAA include:
Demographic information
Health conditions, including diagnoses and test results
Clinical data, such as lab results, diagnostic test results, procedures, and medications
Billing and payment information
Photographs
4. Learn how to implement reasonable safeguards to limit incidental uses or disclosures and avoid patient disclosure pitfalls. Remember, the patient is the final arbiter of what information is shared and/or transmitted.
5. Always keep anything with patient information out of the public’s eye.
6. Learn how to discard confidential information appropriately in accordance with your workplace privacy policy.
7. Consult with your HIPPA office or Human Resource office for any suspicious activities that may compromise patient confidentiality. Do not be afraid to ask for the guidelines and workplace security and privacy policies and procedures.
When Jannel D. Gooden, BSN, RN, was a new nurse, the first six months were traumatic for her. Her short-lived time in an adult oncology unit had her second-guessing her decision to become a nurse.
“I went through a spectrum of emotions and confusion, and at the time, I felt very isolated in the experience,” Gooden recalls. “I now know that it is a common thread all nurses share. The novice nurse journey is difficult.”
After she left her first position, Gooden says she made it her mission to create and expand on helping guide new nurses. She currently works as a travel nurse in the pediatric critical care setting throughout California. In her free time, she makes videos which she posts on her Instagram account @NoviceIsTheNewNurse to give advice to new nurses so that they learn and no longer feel alone.
A video posted by RN, BSN (@noviceisthenewnurse) on
Some of Gooden’s videos came about because she read through the journal notes she kept during her first three years in nursing and came up with a topic. She will share what was troubling her at the time in a way that she feels will help other nurses. Other times, she makes videos in response to questions that new nurses have emails or messaged to her. Sometimes, she simply speaks directly from her heart.
“I believe everything I went through in my first few months as a new nurse shaped my passion for helping new nurses in their journey,” says Gooden.
Some of her videos even feature doctors giving advice to new nurses. But she has a specific reason for including them. “We work with physicians every shift, no matter what specialty of nursing we are in. It is vital to patient care that we learn to effectively communicate with our physicians, that we are not intimidated by them, and that we develop a healthy working relationship,” explains Gooden. “Using a physician to offer advice to new nurses softens their identity. It gently takes them down from that unapproachable platform and allows a new nurse to hear advice in their safe place. It allows the new nurse to receive the advice without the nerves of the workplace or the pressures of pending orders that need to be carried out. It provides a new perspective on how they are viewed in the workplace and what is expected from them as a team member.”
A video posted by RN, BSN (@noviceisthenewnurse) on
The term “new nurse” doesn’t just necessarily mean someone fresh out of nursing school. Gooden says that when she switched to the critical care field, she became a new nurse all over again. “Every day was a mental, physical, and emotional workout. The equipment was unfamiliar, the families were scary, the patients and all the wires, the time management skills—some days I was afraid to even tough my own patient,” she says. All that is in the past, but by sharing her experiences with new nurses, she is making a difference.
Gooden gets asked a lot of questions, and Minority Nurse asked her about advice she would give to new minority nurses who might be experiencing discrimination, bullying, and/or stereotypes. “Discrimination and bullying are topics we sweep under the rug in nursing school. No one seems to talk about it, but it is a very real thing for new nurses of all ethnic backgrounds,” Gooden says. “New nurses carry a certain enthusiasm and hope that all nurses need to be reminded of it. My greatest advice is to hold on tight to your light. Try not to get discouraged in your practice during the very inevitable difficult moments. Your work will speak louder for you than any words you could ever speak, so do not get lost in the stupidity of others. Be an advocate for yourself. Do not allow anyone to treat you unfairly. Know when and how to put your foot down, all while maintaining your professionalism.”
Top Five Pieces of Advice for New Nurses
Gooden has top pieces of advice that she would give to new nurses, and they focus on what she believes are not emphasized in nursing school, a consistent part of the nursing curriculum, or ingrained into nursing training.
1. Be Confident.
Your patient cannot trust you, if you cannot trust you.
2. Know How to Delegate.
We are taught the meaning but not taught how to execute the verb. One piece of advice I always suggest? Get to know your CNAs and PCTs. This creates a more comfortable environment for you to be able to ask them to complete a task for you. It also shows your respect for their line of work by getting to know them outside of your needs.
3. Vent.
Find a friend and let it all out—preferably a nursing buddy you can trust. If you do not release the frustrating energy in a healthy way, your patients will feel your tension. When you are tense, you are also more inclined to make mistakes.
4. Don’t Be Afraid to Ask Questions.
Question everything! Ask every why and how that comes to mind. The new nurse who does not ask questions is the nurse that scares everyone on that unit.
5. Be an Advocate.
Knowing how to advocate for yourself is truly what makes you a more comfortable advocate for your patients. So please, speak up for yourself.
Gooden is in the process of creating a YouTube channel featuring her advice for new nurses. In the meantime, you can find them on her Instagram. “I want to help new nurses because I am forever that new nurse. If one fails, we all fail because we collectively make up a profession that the world depends on,” says Gooden. “I want new nurses to gain confidence with their practice because people do not stop getting sick because we are afraid. Once you can overcome fear as a new nurse, then the door to growth is wide open.”
