An angry patient is like an artichoke. An artichoke is prickly and rough on the outside, but by taking time to learn how to peel its rough leaves, you reveal the tender inside. When nurtured under the right conditions, this tender inside grows to bloom into a beautiful purple flower. Patient anger is like the prickly green leaves of the artichoke, it’s a barrier to seeing “inside ” and to effectively meeting the patient’s needs.

A patient’s anger usually stems from a source other than you. It might be a generalized reaction to the illness, a concern about insurance, a lengthy wait to see a healthcare provider, trouble finding a parking spot, or perhaps nothing at all related to the visit. Although each person has his or her own specific reason, most patients become angry because we have failed to meet their expectations. Whatever happened to make them angry, they had expected something else.

Dealing with misdirected anger presents challenges. An angry patient yelling at you elicits normal reactions such as the physiological flight or fight response. The angry patient may also elicit emotional responses such as anger, fear, or confusion. Some professionals avoid the angry patient, giving only cursory care in order to get out of the room as fast as possible.

Understanding the normal physiological and emotional responses of our bodies to misdirected anger as well as the consequences of not dealing well with the angry patient brings us to some important ways to help work with these special patients.

Listen well

While nurses typically excel in the art of communication, many of us need to improve in the art of listening. Listening is a particular challenge when an angry patient is yelling. Active listening begins with sending a clear message that your major interest is hearing what the patient has to say. Introducing yourself and asking permission to sit (not on the patient’s bed, of course) sends this message. Standing, especially by the door or over the patient in bed, sends negative messages.

Eliminate unnecessary distractions, such as the TV or radio. If guests are present, ask the patient to decide who should be present during the discussion or if another time might be better.

Now comes the difficult part. After you ask the patient to tell you his or her concerns, wait at least one full minute without interrupting, no matter what is said. This is the “magic minute “.

Be aware of your body language during this time. Lean forward and make sure you have good eye contact. Keep your focus on the patient, not on forming questions or statements to say when the minute is over. Really hear and listen well. Let the patient feel as if you have all the time in the world to listen. Don’t touch your watch or even glance at the wall clock.

The only exception is if the patient uses use obscene, profane, or otherwise offensive language. Every patient’s concern should be heard, but nurses have the right to be treated civilly and not be subjected to abusive language. Should this happen, it is absolutely appropriate to draw the line and say, “Mr. Smith, I really want to listen to your concern, but I can’t do so if you continue to use foul language.”

Remember the artichoke: What may seem “prickly” and unattractive, such as an undesirable encounter with an angry patient, has a deeper meaning once you peel away the outer layers. The patient’s anger is usually not directed at you, so don’t take it personally.

Case Example

A young father and his two-year-old son were on a pediatric unit. The nurse went in to perform a sweat test to rule out cystic fibrosis. After appropriate explanations, she started to place the electrodes on the child’s arm. Before she could start the test, foul language came out of the man’s mouth as he stared the nurse in the eye threateningly. He kept up a continuous stream of threats and foul language while holding his two year old. The nurse told him that she could not perform a test with him talking that way. She also told him she would return to perform the test when he calmed down.

Several minutes later the father apologized for his outburst, and related his fears regarding his son’s illness. Upon further inquiry, other staff members reported that he displayed the same behavior when they would approach the child, but they just thought he was an “angry father” and only entered the patient’s room when absolutely necessary. The nurse who listened to the father was better able to meet his and his son’s needs.

Recapitulate

When the magic minute is over (it might be longer than a minute), it is time to check to see if what you heard is what the patient intended you to hear. This is done by a recapitulation or summary of their complaint, and asking for feedback. “So Mrs. Doe, as I understand your concern, you expected your sponge bath at 8 am but didn’t have it until noon, and that this happened every day during your hospitalization. Is that right?” If the patient doesn’t agree with your summary, keep asking questions and summarize until the patient expresses a sense that you are “of one mind” on the issue.

Empathize

Because we have not met their expectations, patients develop emotional responses to the situation. While we often see only anger, many times there are other feelings such as despair, resentment, sadness, or helplessness that must be addressed to satisfactorily resolve the patient’s complaint. All patients want to know that people care about them and their problem.

Nurses can learn empathy if it does not come naturally. Imagine yourself in the same situation. How would you feel? How would you want to be treated? Make sure you do a reality check with the patient by asking questions to make sure you are on track with the emotion. Above all, be genuine. Most people detect false emotion even when meant with good intentions.

If your emotional compass does not point to the empathetic, then say something like, “I can understand how that would make you feel like that.” Don’t focus on yourself by saying you had a similar situation — the patient does not care about that now. Connecting with empathy to your patient helps diffuse his or her anger and facilitates a resolution to the issue.

Resolve the problem

Expressing feelings and concerns can certainly be therapeutic for the patient, but we must also address the issues at hand. One effective method is to let the patient offer a solution. What would make him or her feel better about what has happened? When we make assumptions based on our past experiences of what people expect, we may be incorrect, and we risk not meeting the patient’s needs. “What would make you feel better about this now?” is a question that clearly seeks the patient’s expectation and places the focus on the present and future, not the past. You may not be able to solve all of patients’ problems, but a pledge that you will make their concerns known to the appropriate people typically is well received.

In the thick of it

A little-known fact: Artichokes are thistles and are a very labor-intensive crop. A known fact: Nurses are in a very labor-intensive business that requires expert skill in the art of communication when dealing with the angry patient. Equipping yourself to deal with the angry patient helps you care not only for you patient but for yourself as well.

Katherine Rossiter is associate and Stephen Lazoritz is principal for The Lazoritz Group in Omaha, Nebraska. Rossiter is also an adjunct professor of nursing at Olivet Nazarene University and adjunct faculty in ethics at University of Phoenix.

References

California Artichoke Advisory Board (CAAB). http://artichokes.org/. Accessed July 7, 2011.

Huntington B, Kuhn N. Communication gaffes: a root cause of malpractice claims. BUMC Proceedings. 2003;16:158.

Lazoritz S. Dealing with angry patients. Physician Executive. 2004;30(3):28.

Wang E. Dealing with the angry patient. The Permanente Journal, 2003;7(2). http://xnet.kp.org/permanentejournal/spring03/angry.html. Accessed July 7, 2011.