Dealing with the Difficult Patient

By Carol Mulvihill, R.N.,C., Editor

Although my experience in dealing with most students who seek our services is positive and cooperative, every now and then a very challenging student comes through our doors. I'll tell you candidly how I handle these situations at the University of Pittsburgh at Bradford's Student Health Center. I don't pretend to have all the answers, nor am I proposing that my approaches are exemplary or useful for everyone. I am simply offering food for thought and honest discussion. At the end of this article, I will ask for your input in the form of strategies, anecdotes, and examples from your own experiences and observations.

First, I will attempt to define what I mean by "the difficult patient." I was going to title the article, "Dealing with the Rude Patient," but someone suggested I use the term "challenging" instead. I think "difficult" is more descriptive, as I am talking about negative behavior here. Some of the other terms my co-workers came up with in describing such behavior include: inappropriate, demanding, cocky, bossy, and angry. Those are the words I can print.

Here is what I do:

Invite the student to sit down

Somehow, sitting tends to disarm or at least diffuse the "fight or flight" pattern of behavior. It seems more difficult for a person to yell at someone from a sitting position. Sitting also helps remove the person from a domineering stance. Have you ever noticed how a demanding student will stand over you or your desk and give orders? And somehow they are always in a big hurry.

Set the volume, tone, and speed of the conversation.

When a student comes in hurried, and with a demanding tone of voice, I purposely make my volume and tone of voice a definite contrast to their own. Sometimes they notice the contrast and calm down, sometimes not. I make every effort not to fall into the trap of matching their attitude, tone, and volume.

Our Director of Residential Life and Housing, Rhett Kennedy, is a very even-tempered guy, who does a remarkable job of staying professional at all times, regardless of what is being hurled at him. Rhett is very good at using the "Kill 'em with kindness" approach.

Listen to the person, then remind them to listen to you.

It seems that often when someone is angry or irate they suddenly develop a hearing problem and tend to speak loudly and interrupt repeatedly when you try to talk to them. I do my best to listen to a student first. I tell them that I will listen to everything they have to say as long as they keep the volume down and the attitude courteous. But then, when it is my turn to talk, I expect them to listen also.

By encouraging a student to control the volume and tone of his/her voice during a conversation, as well as reminding him/her to listen, we are encouraging the development of positive communication skills which can reap life-long benefits. This fits with our philosophy of student development.

Confront them on the bad behavior

If other approaches fail to bring positive results, I believe there is no choice but to objectively point out the bad behavior. A couple of weeks ago, I had to deal with a particularly rude student for the second time. I calmly looked at him and said, "Listen, you have been demanding and testy both times you have been in here. If you want my cooperation, that behavior has to stop now."

Jane Boudin, our part-time nurse, reminded me of a more tactful, therapeutic which we have used in the past with angry students. Say to the student, "Your reaction to this situation seems out of proportion to the problem. Is there something else going on with you that you would like to talk with me or a counselor about?

In an uncomfortable situation, call in another staff member.

Sometimes it may be important to have another person there to witness the conversation. Our staff have an agreement that if anyone hears angry shouting, they check it out.

Ask the person to leave.

My boss has told me that we do not have to deal with students who are rude, obnoxious, or discourteous, and should request that they leave.

Last week I had to deal with a student who was raising his voice at me. He seemed to turn down his voice volume somewhat as I made it a point to speak softly in response to him. But he still reverted back to speaking in a demanding, critical manner before the visit was finished. I really would have liked to have kicked his butt. (Of course, none of you have ever felt that way ; ) Monday morning quarterbacking, I thought I should have said to him immediately, "Your behavior is inappropriate. If you want to do business here, you will speak in a courteous, civil manner, or come back when you can do so." Maybe if I rehearse that line, I'll remember to use it next time. Of course, hind-sight is always 20/20.

I report student behavior problems to my boss.

This is for my own protection. It can also be an enlightening experience. Sometimes, a student's bad behavior is not just a problem with the health service, but is a symptom of a deeper problem, manifesting itself in other areas as well. Once when I told my boss about my experience with one particularly difficult student, I found out that he had been suspended from a sports team for bad conduct and a drug violation. He was referred for counseling.

Also, my boss, Jim Evans, Vice President and Dean of Student Affairs is particularly supportive of our staff. He and I have problem-solved many crisis situations together. In a small college situation, where you are the lone nurse or have few support staff, involvement of your boss is essential in resolving student crises and difficult situations. Working alone doesn't mean you are expected to resolve everything yourself.

We put up a sign!

Following a particularly difficult incident last week, I put up a sign in the waiting room "$10 Fine for Rudeness." Our Administrative Secretary, Cindy Cavallero, smiled and said, "What are we going to do with all the money?" Rhett said we should list different categories of rudeness, such as, rude comments $10, and rude gestures $50. We chuckled...and so will many who read the sign. It is a subtle reminder, nevertheless. Interestingly enough, everyone seems to have been particularly courteous since the sign went up.

I also realized that professional comradery, a sense of humor, and sharing the problem do much to heal the wounds of a negative experience.

Of course, posting a statement of student rights and responsibilities would be a more appropriate reminder, and I will do this now that I have so many wonderful examples after which to model our own statement. In the meantime, the fine for rudeness sign stays up because, at least for the time being, it seems to be working!

Your Opportunity for Input

Readers, here is your opportunity for input. Click on my email address below to send me a message containing your own strategies, anecdotes and examples from your own experiences and observations in dealing with difficult students. Please indicate if I can print your comments in CQ. Also, please tell me if I can print your name along with your input, or if you wish to remain anonymous. Of course, all submissions are subject to the editor's review and discretion.

Email to Editor Carol Mulvihill cjm6+@pitt.edu

Thanks in advance to those who contribute helpful and practical solutions for the benefit of all. : )

Go to the list of articles in the Winter 1996 Issue of CQ.