May 01, 2012, By: Wendy Dixon, RN, MA
“That hurt, you stupid bitch.” I was a student nurse doing my clinical rotation on a surgical unit. My patient was approximately 65 years of age. Aside from the need for an emergency appendectomy, he was healthy, but he had a long-standing aversion to doctors and medical care in general. I was prepared to change the dressing and cleanse the wound; what I wasn’t prepared for was the abusive commentary. I managed to get through the tasks, but his hostile comments felt personal, and they devastated me emotionally.
Flash forward one year. As a new grad, I was required to spend 45 minutes every morning with a pipe-smoking double amputee with necrotizing tissue and extensive dressings on both legs. It was 45 minutes of hell. His hobby was to terrorize new nurses. I don’t know if I was hormonal or just fed up on one particular day, but I lost my temper, swore and told him exactly what I thought of him, finishing with “You can lie in here and rot for all I care.” My obnoxious patient looked at me, took a long draw on his pipe and said, “You sure have a potty mouth.” Amazingly, my “nursing intervention” had a magical effect on this man, and our time together became one of the highlights of my day.
Having a temper tantrum is not a strategy I recommend, and it is one unlikely to be embraced by your nursing association or your boss. That blow-up made me realize that I did not have the skill or the psychological armour I needed to care for people who are verbally abusive. So I looked to nurses who seemed to be able to manage the problem with ease and grace. I observed their interactions with patients, talked to them and eventually picked up 10 secrets that work to de-escalate situations in which a patient is unpleasant and even angry: apologize, appreciate, agree, show concern, empathize, distract, humour, praise, be silent and validate. As a disclaimer, I will advise you to use these strategies at your own risk. They could make the situation worse, but when they work — and they often do — the result is pure magic because these patients, many of whom are ready for a fight, are caught off guard.
A simple soothing statement can change the whole dynamic of an interaction. So find something to apologize for. “Sorry you are such an ass” likely won’t be received positively, but “I’m sorry I have done something to upset you; that wasn’t my intention” may work wonders. Appreciate what is being expressed: get past the abusive noise and say “Thank you for bringing this to my attention; I will see what I can do about it.” Find a point of agreement: “You’re right. No one should have to wait four hours in an emergency department.” Show concern: overlook the words and tone and focus on the patient: “Are you OK? You look pale.” Empathize is a word readily repeated by those in the nursing profession, but it is a complex concept. Unless one has had the same experience as the patient, putting the concept into words with feeling may fall flat. Empathy can be demonstrated, however, with a warm look and a purposeful touch on the arm or hand.
One of my favourite strategies is to distract; this requires thinking fast on your feet. In the midst of a patient’s diatribe, create a distraction by commenting on something in the immediate environment: “Is that a picture of your daughter? She is so beautiful.” Humour is less about making a joke (although it can be) than about finding the humour in the situation you find yourself in. I highly recommend that you develop this skill as a survival strategy and share it with others. Praise: everyone likes to hear good things about themselves, even when they are behaving badly. It can be difficult but not impossible to come up with some honest praise: “You really did a great job of being patient for this long.” Silence is golden. My mother used to tell me that if you don’t have anything nice to say, don’t say anything at all. I’ve come to prefer an adaptation of her advice: Don’t take the bait. Validate the patient’s experience. Respond to someone who says “I am so angry right now” with “You have every reason to be angry.”
Given the overwhelming evidence that shows nurses deal with verbal abuse on a regular basis in their day-to-day work, it was disconcerting for me to discover that the literature reveals little information about organizational strategies and interventions required to provide care to patients who are verbally abusive or to deal with this abuse from others within the workplace. The individual skills, knowledge and competencies required to successfully navigate verbal abuse have also been ignored in the literature. Position statements and policies that pronounce zero tolerance are noble and well-intentioned, but there have been no critical reviews in the nursing literature as to how effective they are. Verbal abuse will never be eradicated from the health-care landscape. But if nurses share their knowledge and acquire the skills they need to de-escalate difficult interpersonal situations, they will gain confidence and control in dealing with them, leading to more positive outcomes.
Wendy Dixon, RN, MA, is Facility Manager, Golden Prairie Nursing Home, Indian Head, Sask.