Nursing is regularly rated as one of the most trusted professions, but nurses are also the target of allegations of abuse and negligence of patients. We are at particular risk because of the intimate nature of our jobs, which necessitates closer-than-normal proximity to the patient’s personal issues. Patients who exhibit manipulative behavior such as attention-seeking may be more likely to allege that misconduct has taken place. For this reason, nurses must learn to effectively care for these patients by using therapeutic communication and accountability measures.

The nature of manipulative behavior

Geriatric patients are more likely than younger patients to engage in manipulative behavior such as attention-seeking and accusatory behaviors. In the long-term care setting, feelings of abandonment can lead to attention-seeking behavior such as excessive calling out for a nurse, lying down on the floor and then calling out for help, and complaining of pain then refusing interventions. In the acute setting, patient distress because of sudden changes in health status, diminished functioning, and cognitive changes may cause geriatric patients to engage in accusatory behaviors such as claiming a nurse did not respond to requests for pain medicine.

Manipulative behaviors typically arise from either a sense of insecurity or powerlessness. There is direct correlation between manipulation and the need for control over circumstances. It’s important to determine the root cause of the behavior. Assess for stressors or changes in clinical status that may be causing the behavior. Discomfort in the form of pain, temperature changes, loneliness, and fear are common factors that result in manipulative behaviors. Understanding why a patient behaves in a manipulative manner will cue you to the appropriate course of action.

Nursing diagnosis

An appropriate nursing diagnosis associated with attention-seeking and accusatory behaviors is anxiety related to diminished autonomy as exhibited by manipulative behaviors. Report episodes of anxious behavior so that the physician or nurse practitioner can order a consult for a psychiatric evaluation as appropriate. Antianxiety medications can be used, but should be considered only as a supplement to nonpharmacological primary nursing interventions. The interventions for anxiety revolve around certifying that therapeutic communication and accountability is put into place.

Therapeutic communication

The hallmark of effective and therapeutic communication is the active listening of an assertive nurse. As Radtke writes, “The nursing process, moreover as a scientific method of exercise and implementation of nursing, is achieved through dialogue, through interpersonal environment and with specific skills of verbal communication.” Speaking in a clear and direct manner, maintaining eye contact, using a moderate tone of voice, and presenting oneself professionally are forms of therapeutic communication. While rendering superb nursing service is always the goal, asking questions in a way that limits the answer to affirmative or negative responses may be beneficial. This will give the manipulative patient less opportunity to become agitated or anxious.

Discussing realistic expectations of time and resources available with the patient is of paramount importance. This establishes boundaries and forms a solid foundation on which to build future rapport. The patient will learn that you can be trusted because you will practice with integrity. By putting forth realistic expectations, you can mitigate many manipulative behaviors exhibited in the healthcare setting.

Work with the family and develop a trusting relationship that can be used in the event of manipulative behavior or claims of misconduct. Conduct progress meetings with both the family and patient present to ensure expectations are understood by all parties.

Accountability measures

Accountability is a crucial facet of taking care of a patient with manipulative behaviors. By making yourself accountable for a patient’s care, the patient will be less likely to allege misconduct from you. The formation of a partnership ensures that both parties are striving for the same goal.

One of the best ways to become accountable for exemplary care is to advocate for the patient’s autonomy. Giving the patient choices regarding his or her care restores a sense of control that is imperative to feeling secure. Many times the lack of a routine or schedule prompts a patient to allege that the nurse is neglectful. Formulating a schedule and faithfully notifying the manipulative patient of changes will demonstrate that you believe he or she is worthy of your time and efforts.

There are many specific interventions that may be put into place by an interdisciplinary team caring for a patient who exhibits manipulative behavior. For example, designating one caregiver to be the patient’s contact will result in more consistent care. Having two staff members present for all patient interactions will ensure that any claims of misconduct can be evaluated for validity by multiple healthcare professionals.

Remember to communicate the full clinical picture of the patient’s behaviors to the oncoming nurse to cultivate competent and consistent care throughout all of the shifts, and document each episode of the manipulative behavior, outlining what interventions are currently in place to ensure the delivery of evidence-based best care.

See Therapeutic interventions for manipulative patients for a summary of interventions.

Unconditional care

Although dealing with manipulative behaviors can be frustrating, nurses are trained to care unconditionally. In most cases manipulative behaviors aren’t personal, but rather the patient’s last attempt to gain control of a situation. Be compassionate to patients who present with difficult behaviors. Every professional nurse is called to provide holistic and competent care.

Douglas A. Kemerer is a resident care manager at Frey Village Lutheran Social Services in Middletown, Pennsylvania.

Selected references

Kable A, Guest M, McLeod M. Resistance to care: Contributing factors and associated behaviors in healthcare facilities. J Adv Nurs. 2013;69(8):1747-60.

Radtke K. Improving patient satisfaction with nursing communication using bedside shift report. Clin Nurse Spec. 2013;27(1):19-25.

Ruch S. (2012). Primary nursing: a call for clarity, empowerment, and accountability. Creat Nurs. 2012;18(4):175.