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Dealing with Challenging Patient Behaviors in the Workplace

Mark A. Hyde, MA from Mayo Clinic, with 20 years experience in crisis settings, gives 3 tips to keep yourself okay in spite of challenging patient care.
Mark A. Hyde, MA
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I. UNDERSTANDING WHERE YOUR PATIENTS ARE COMING FROM AND WHY THIS SITUATION CAN BE DIFFICULT


PATIENT BEHAVIOR CAN BE DANGEROUS FOR YOU AND YOUR MENTAL HEALTH

I've been at Mayo Clinic for 20 years here, so I've seen thousands of our employees, frontline providers, all the way up to senior providers. And the more time you spend with patients that are going through some difficult times, the more you're going to be exposed to some challenging behaviors, personalities, and dispositions.


And mainly, the tips that I'll show today are mainly geared toward how to keep yourself okay in spite of some challenging situations. One of the things that you're pretty well aware of that I've seen here around the nation is an escalation of some patient behaviors, especially in the hospital situation, everything from incivility to work to violence. 


Patient violence, throwing, kicking, spitting, biting, hitting. Lots of things are happening around the nation with this. And it's drawing great attention, rightfully so, to a lot of people in leadership, administration, security, and nursing to try to figure out how to manage this. Well, I'm not really talking about that but a little bit more about in your particular area.


YOUR PATIENT’S HUMAN NATURE

I do a lot of work with leadership here in managing employee behavior in the workplace, dealing with an array of personalities, dispositions, and how people emote that in the workplace – the emotions, words, and behaviors that they express. I think it's one of the major areas that's under-focused. 


Sometimes, we get caught in the naivete of, if you just do this, the person will do this. Why don't you just try this? Sometimes, that works. Sometimes, nothing will work. And for our leadership structure, sometimes people get caught. Maybe, you should manage the situation as opposed to trying to figure out the really complicated neuronal structure of people.


How do I disengage? I get so emotionally reactive to this patient. It really frustrates me, and I'm coming across the wrong way. And how do I engage or re-engage with them and then maintain positivity? 


I do have a spring in your foot and your balance. Once in a while, when I meet with people who are dealing with daily, sometimes weekly, frustrating patient issues, I would come to work still 

and have a positive attitude and maintain and actually interact in such a way that I keep me. 


Another way to talk about this, a term that's used a lot, resilience, but basically, how do I keep myself okay, in spite of some of the challenges around us? Often, what people initially think about is that our disposition, our personalities, how we express ourselves – the most complicated thing in the universe. We don’t have to ask a physicist or a scientist or any person off the street and ask, “What is the most complicated thing in the world?” They will usually come back to the same place, the brain. 


THE PREDICTABILITY OF YOUR PATIENT’S BEHAVIOR 

It's incredibly complicated. Sometimes, it's very simple. People in relationships, you can predict their behavior. If you have teenagers, you can be very good at predicting what kind of behavior or maybe they're going to exhibit. Other times, of course, you and I scratch our head and go, “I can't believe this person would say or do that.” “I can't believe my spouse would say – you know me! Why would you think that?” 


So, we think of the great diversity, the complexity of thought. I've made a living kind of talking about perception, diversity of our perceptions – not race, ethnicity, just our diversity of anatomy, of thought. The anatomy of thought is what makes me, me and you, you. How I perceive the world. The inputs that come into me. 


And what happens when it goes through billions of special cells, neurons in the brain, trillions of connections in the brain, the incredible brain mapping information, neuroplasticity that we have today, kind of the studies – which are fascinating about recovery and how the brain responds to injury, illness, disease – and how people misinform, misinterpret information, at times. How many of us, at times, feel, “How could you possibly get that out of what I just said?” I’ve said that to my wife once in a while, and we've been married a long time. Thirty years. 


Other times, of course, you already know what the other person is thinking before you even express it. So, there's great complexity and diversity. And as you're dealing with patients that have multiple issues, maybe chronicity in pain and other factors, disease, we add their personality, we add these things, which is what? 


THE LOSS OF CONTROL

As you all know, when we have more and more thoughts about the loss of control, our behaviors even change, more so as the opinion on the disposition of the person. About loss of control and what comes out of us, some people are very combative, and some people withdraw and go into their own world and become apathetic and feel helpless and tearful. Other people will be very non-compliant. Combative. Wide variety and everything in between. 


We're really talking about emotional regulation, yours and maybe the patients. I do a lot of work with extreme behaviors at times, where people say, “look, I can manage the stuff that I expect,” in some of those individual things that are above and beyond maybe two or three deviations past the mean, so to speak. 


And I have to do a lot of work sometimes remind people that most of us, but not all of us, can have an event that happens, and we get a kind of spontaneous feeling that happens. Doesn't take much to get a feeling. And as we grow, we hope that we take that feeling, and we think with the prefrontal cortex about: where am I at? How do I express these social norms, my at work, my church, my in the hallway? Where am I? How do I think through and express that? 


Some people have an emotional feeling of emotional thought based upon an event, and they go right to behavior, sometimes they bypass that. Very strong, right? And of course, we've all been rewarded for our behaviors over the years. People like that, I always joke a little bit. Bobby Knight. Mike Ditka. Some people may know some of those people that are in the media, their sport ethic.


“I've been around a long time throwing chairs on the court as a basketball coach,” really frustrated. And they get rewarded for their behaviors. I joke around and say to a lot of people say, “Look, I've seen people return things at Target that have rust on them, and they still get the people to take it back.” Why is that? Because it makes somebody uncomfortable. This person is used to arguing enough and maybe they get somebody to reward their behavior. You might call it a negative reward. For kids, they don't eat their peas, and we give them cake. We give them a kind of a negative reward. And the same can happen when behavior. 


INDIVIDUAL EMOTIONAL REGULATION

So, the person my point is in front of you or me as a patient, we have no idea all the complicated inputs: DNA, family, trauma, their own hard wiring, neurologic wiring, how they view things and interpret the world based upon their senses. Always remind people how different we are. 


Think about foods. I had kids at home that I would you know, I would try to do everything to get them to eat a different variety of foods. One of them would be anything and everything. Had no idea what it was. One of them would eat nothing unless they knew what it was. It smelled okay. And the initial taste was OK. Does anybody else have any of those kids at home? 


And it has a wide variety in our thoughts, our views, our taste, our likes. Some people like to bungee jump. Anybody here bungee jump. Well, a couple of you, right? I would rather say shoot me if I was at the end of that having to shoot. I mean, I would rather just die right then, I think. As opposed to bungee jump, IBL says, “Yes! this is a great experience.” So, we're very different. 


So, emotional regulation is gonna be very different from people and certainly patients, as you already know. And it's going to be very complicated. And at times, it's very simple, and other times, it's very complicated. And there's not a whole lot that I may be able to do to help them with their emotional regulation, but how do I maintain me in spite of them?


HOW TO KEEP YOURSELF WHOLE AMIDST THE CHAOS OF PATIENT CARE

How do people's expectations, in other words, manifest out to the world, and how do people express their thoughts? When I do national conferences, and I'm talking about organizational behavior, and I use the word entitlement in the crowd, especially it's a leadership group, I get a lot of reaction with thoughts about entitlement. And because our society is very different than what it was maybe 20, 30, 40, 50 years ago, people have immediate expectations, sometimes much stronger, sooner in their world of work than we did years ago. 


And so we have to expect that in leadership – how do you respond to people who have strong views? From Vernors, managers have told me they have a new nurse on the unit who's been here a couple of weeks and has a new matrix for staffing that they'd like to present. And you can imagine what that might do, of course, to some of the senior people that have been around, saying, “Are you kidding me?” Right? But on the other hand, we can expect some of that because our world is changing. 


It's hard to keep yourself. I’ve worked in crisis settings. Gang kids in Chicago, crisis centers where police drop people off, first responders, done a lot of this over the years. And a lot of it was trying to figure out how do I keep myself together? And so these are tips from me and tips I learned from thousands of people. 


II. 3 TIPS FOR MAINTAINING YOURSELF AND NOT LOSING YOURSELF IN CHALLENGING PATIENT BEHAVIORS


  1. DISENGAGE

When you're dealing with a very difficult patient interaction, whatever difficult is for you, because it could be different, one of the big things we have to do is find a way to disengage emotionally. Not in a bad way, but in a good way, because you're fighting your natural tendency to be reactive. We're naturally built and wired to respond. And often somebody says something that bothers us, we have a natural tendency sometimes to defend or respond. And it's almost overriding the natural circuitry in this situation. 


So, patient behavior is generally not about you. And that's important for us to remember that as a framework because it's about so many other things. I think of the first responders that I work with – they get on a scene, and there's a lot of emotionality going. What are they usually do? They go to, “What's your name? Where are your injuries? Is there anybody else there,” they’re trying to get information. They're not paying attention to, “What do you mean I'm being mean? What do you mean nobody cares?” I mean, they're not going there. They're going with their information that they know they need to help this person in spite of what the person is kind of exhibiting at that point. 


YOUR PATIENT’S SHOCKING BEHAVIOR IS CRITICAL INFORMATION

And the same may be true for you in some way. Their behavior is information. So for me, it's information for me to use. If it's extreme anger, if it's apathy, it's frustration, hopelessness, that's good information for you to kind of figure out where are they at. 


When I was working with people in crisis centers, one of the things that we would use often is an incidental kind of touch on the shoulder after a violent incident just to see where they're at. And they would tell you. A general touch on the shoulder, if they jumped back, I knew they weren't ready yet for more de-escalation. I was going to keep them where they were. On the other hand, if they don't respond to that in a negative way, then it gives me more indication to keep talking. 


HOW TO UNTETHER YOUR EMOTIONS TO THEIRS – PREPARE TO BE SHOCKED

So, the behavior is information for you to use where they're at. Their frustration, their hopelessness, their tears, or their combativeness with you. It's information to use. And it’s one of the keys that has to be remembered because often people get caught in the moment, say, “I was so shocked by that.” And that's true. We almost have to be ready to be shocked, right? 


When I'm ready to be shocked, I work better than when people just shock me. Then, they get the central nervous system wired a little adrenaline gets pumped, and you get into fight or flight. And how you're wired, you either get the fight or the flight, quite frankly, right? You can either say things you wish you wouldn't have because you’re angry too, or you can get so nervous about it, you're not sure what to do. 


So, your inner emotional world shouldn't be tethered to theirs. People see me all the time, and they get mad at me when they think I can get them a new job, or I could do something opposite of what has happened to them in the workplace. That's not my role, but I'll help them think through, “What good are you? Why did they come here?” And so I don't react to that. Younger days, I probably did a little bit, but I don't react in quite the same way as I understand they're really frustrated. 


Even though I told them upfront what I don't do, they didn't hear that because they were convinced that if they told me something else, I would do something else. I'm not tethered to them, so they don't respond in a way that's reactive to where they're at. 


  1. POSITIVE ENGAGEMENT 

Your algorithms, you have a lot of them, I know, and they're based upon the information that the patient gave you. They’re not based upon just the emotionality, although some of that, but certainly, your direction is figuring out where do you want to go to problem solve this, as opposed to managing your own reactions and your own emotionality. 


Your activity and your world is managing your inner thoughts. And at times, for some of you, that's easier than others. Right? Some of you get really, really offended, maybe easily more so than someone else. You wish you didn't, but you do. And it can frustrate you when you're trying to help this person, and they're not being compliant. You're gonna let them know, quite frankly, here's what would happen if I do this, here's what happens if I don't do this. My only care for you. I say to people all the time, “I'm sorry, I can't tell you what you would like to hear. I wish I could, but I can't. But here's what I can tell you.” And I stay with that a lot. And I found that has been kind of a statement that's helped more often than not. 


Most often, patient compliance is not a reflection of the skill of you as a provider, as a caretaker. It's what's going on inside the complicated world, inside somebody else. There are billions of neurons, the DNA that they have there, their environment, the rewards, who they are, their unique view of the world, and what they view as fair or not fair. Okay or not okay. And that's what you and I sometimes are in the middle of. 


  1. BUILDING A SOLID FOUNDATION OF POSITIVITY

People ask me this all time, well, how do you maintain a sense of positivity, joy, even attitude when you're dealing with a lot of ick? Not all the time, but a lot, and maybe some weeks are worse than others. I use that word tethered a lot. I don't want to be tethered to other people in the wrong way. I want to have a solid foundation and framework. 


I have three kids, and they're all raised now and out of the house, but they had different personalities. My foundation was always the same in dealing with them. Right/wrong values, discipline, but the way that I navigated it would be different based upon their personalities. So, my oldest, I could yell, and I could be really loud and boisterous, but it didn't bother him. He was still kind of difficult, oppositional. And then, I had the youngest, who I could just kind of look at him when I was frustrated, and he would behave. 


I say sometimes, “Thank goodness, it was my last.” Otherwise, I'd be really frustrated because my first, I thought I really messed up. He's great now. But I mean, just the idea that going through the personality differences, they tell us who they are, and they're very different. 


TRULY APPRECIATE WHO YOU ARE

I had somebody say to me not long ago who is my age, 20 years or so (50’s), and he said to me, “Look, I've I have an issue with one of my co-worker providers, and we get disagreement about patient care stuff. And I don't respect them and respect me. And I told this person until they respect me, I'm not going to respect them.” And I thought to myself, “Well, that's kind of what we did in fifth grade.” And my point was him trying to say, “Look, you can still be you. You don’t have to be tethered to somebody else. It doesn't mean you're blanket/doormat and all that. That's just me. You may have to set a boundary. I'm not going to talk with you when you're yelling at me or using that language.”


However, I'm gonna be me. I'm not going to react to you. That's called emotional maturity. That I don't need to come down to that level. Be comfortable with who you are. Don't make it that kind of the eight-year-old kind of thing, “If you talk nice, I'll talk.” We don't do that. Truly appreciate. 


I assume when I say I always do the right thing, I'm assuming your high character, your integrity. Doing the right thing even when it doesn't feel good. Even when you feel like you were treated by that patient, “Gosh, I didn't deserve that.” Well, of course not, but again, that patient has all kinds of other things going on. I’m not going to take that personally. 


Some people can do that. Some people have a really hard time doing that. But the only way I know to do that is to have a foundation inside that really believes that. It says, “Look, I can disengage appropriately because I know there's other stuff going on.” I don't take that about me, no matter what they say. And always do the right thing, no matter what they do. 


I truly appreciate those who are grateful. The work that I do, every once in a while I get a thank you, but that's every once in a while. So, my nature is I'm not looking for that. If I look for that or look for positive plugs, I’m going to get really depressed. So I say, look, truly appreciate those people are grateful, know that you're doing the right thing, you're planting seeds, whatever you're doing. And when you get a few people, you really take that to stock. It's a minority, we don't get a lot. I love it, once in a while, when somebody just comes back to my office, and says, “I just want to give you a follow-up.” And I'm waiting for like the worst of the worst, like how I messed up, and you didn't help me. And if they give me something positive, I'm like, “Oh, wow. Bless you. Thank you so much for stopping by.” Just ten minutes to say, “Hey, things worked out.” 


GET YOUR SENSE OF PURPOSE OUTSIDE OF THE HOSPITAL

And then the last thing that I think is really important is making sure that work is not the only place that we get our plugs, our sense of worth and purpose. I work with physicians, frontline staff, and support staff, and I've seen all areas get caught into this at times. Before I came to Mayo, I spend a lot of time with people in business at very high levels who put all of their life, their efforts sometimes, into their work. And when work kind of fell, right, when there was conflict, when something happened that surprised them, their entire world is turned upside down.


I tell people, make sure you have other stuff going on in life. Work is incredibly important. We spend, as we know, a third plus of our life at work or more. So, clearly work is important, but must make sure that you're getting your self-concept, your self-worth in other places, not just work because we don't want it to be connected to circumstance. 


I do some talks on happiness versus joy around here. And, you know, I tell people happiness isn't always the right goal. It's a nice thing. It's circumstance. One minute the phone can ring and change your happiness in a heartbeat. So, we're tethered to circumstances as opposed to joy, being tethered to who I am and what I stand for. And even in the midst of tornadoes, I know there's the purpose, there's meaning, there's worth. And therefore, I can stand on not shifting ground, but on solid ground when things are challenging. 


Great health care providers, their heart is in the work. Sometimes, they emerge so much, it's hard for them to pull out all of it and realize, “Hey, there's other stuff that I must get my needs met.” Otherwise, the work can be good at times, and it can be very frustrating, very painful. 

CONCLUSION

In summary, I know I'm not giving you practical to-dos with patients as much as how to keep yourself kind of okay in the midst of storms, if you will, with some of those patients. And it's really about being able to make sure that your framework is tethered to understand you're okay, even though they're not. I'm able to respond differently than when I feel I have to get defensive, respond back, and protect myself in those settings when you have patients that have complicated issues.


And I've seen the best of the best struggle with this, it's not easy. I've seen people come in and say, “Boy, I hardly have ever done this. I can't believe it. I just kind of lost it.” And so, that's kind of a tendency that maybe there are some other stressors going on and that I don't have much room for expansion of this issue. Kind of like if you have a financial issue, and the refrigerator goes out, there's not much cushion. It's kind of a crisis. On the other hand, if you have money to pay for the fridge, would you rather not? It's a lot less stressful, not fun, but at least you can do it. 


The same is true emotionally when people are already dealing with relationship issues, emotional issues, significant other/parenting issues, work issues, financial issues, legal issues – sometimes, they have less of a buffer, so then we'll find it harder. And that's what it's good sometimes to talk with somebody about that to help free up a little bit of room, to give myself a little bit of a breather. So I have a little more emotional room to deal with some of these normal frustrating issues.


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