_________________________________________________________________ Managing Disruptive Patients
TEN STEPS TO SETTING LIMITS WITH PATIENTS WHO EXHIBIT MANIPULATIVE BEHAVIORS 1. Define clear expectations. 2. Communicate expectations positively and firmly. 3. Limit only those behaviors that clearly impinge on the well-being of the patient or others. 4. Make sure that the limits are in the patient’s best interests and are not punitive. 5. Offer a brief rationale for the limit but do not engage in a debate about its fairness or justification. 6. Define the consequences of exceeding the limit, and make sure that they are consequences that can be fulfilled. 7. Hold all discussions related to limit setting on a one-to-one basis, in private. (This limits the opportunity for the patient to involve an “audience” in determining whether the limit is “fair.”) 8. Make sure that all staff members understand the limit and its consequences as they were communicated to the patient. 9. Stand firm in the face of the inevitable testing of the limit. 10. Provide positive reinforcement every time the patient is able to meet the limit. Source: [25; 33] Table 4
Gaining the patient’s trust, although difficult, and sometimes not possible, is something the healthcare professional should work toward. Trust-building behavior includes being on time for treatments or other appointments with the patient, never promising something that cannot be delivered, and remem- bering things the patient has related. In addition, healthcare professionals must accept that patients may say hurtful things and not take them personally; patients who use manipulation make such remarks to everyone. Self-confidence on the part of the healthcare professional is important because patients who use manipulative behaviors will try their best to gain power by undermining the healthcare professional’s knowledge, skill, and competence. Consistency will help gain rapport with patients using manipulation. All staff members must agree on a plan and follow through with it. Individually, healthcare professionals must remain consistent day to day in their expectations and responses. See Table 5 for healthcare professional interventions that may be useful in caring for patients who use manipulative behaviors.
Intentionally developing social maturity, which includes the emotional strength and ego to recognize and deflect manipula- tion, is an important goal for healthcare professionals. Health- care professionals’ benefit from learning to recognize intrinsic rewards such as knowing they have made a difference and helped someone else transcend to a higher level of functioning. For patients who use manipulation, healthcare professionals must clearly set the healthcare professional-patient relationship with appropriate professional boundaries and maintain those boundaries (Schoenly, 2017). Patients often use a combination of charm and manipulation to disturb the flow of care on a healthcare professional unit. These patients can be difficult. One moment one healthcare professional will be the only healthcare professional who can care for the patient and then the patient will refuse to see that healthcare professional (Schoenly, 2017). Reflection on each experience with a fellow team member can be helpful for healthcare professionals. Meeting frequently to ensure all staff members (even non-healthcare professional staff) are applying the same rules to patients who manipulate is recommended. It is critical to understand that the underlying aspect of this personality trait is stable and enduring. It is difficult to change a pattern of behavior, but consistency and a caring and profes- sional approach must be maintained to begin to make a change. The management of “difficult” patients leads to frustration, stress, and burnout for healthcare professionals. The team needs to work cohesively and reflectively and offer support to all team members. Training to work with patients who use manipulation will reduce burnout and increase job satisfac- tion, while continuing to provide care to all those who need it. Mentoring healthcare professional colleagues is highly recommended for situations involving patients with manipu- lative behaviors.
HOLISTIC CONSIDERATIONS FOR INTERVENTIONS
Manipulation tactics can include flattery, interest, or praising one healthcare professional while degrading another healthcare professional. This attempt at control is usually the means to an end; there is some goal in mind for power, entertainment, or privileges. Manipulation is so prevalent in some settings that healthcare professionals have developed theories and strategies to better manage the difficulties associated with these patients’ behaviors (Schoenly, 2017).
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